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languages— German,  English,  French,  Italian,  Russian,  Spanish,  Danish, 
Swedish,  and  Hungarian. 

The  same  careful  and  competent  editorial  supervision  has  been 
secured  in  'he  English  edition  as  in  the  originals.  The  translations  have 
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(For  List  of  Bookst  Pricest  etc.  see  back  coverJ 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
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http://www.archive.org/details/atlasepitomeofopOOzuck 


ATLAS  AND  EPITOME 


OF 


OPERATIVE  SURGERY 


BY 

DR.   OTTO   ZUCKERKANDL 

Privat-docent  in  the  University  of  Vienna 


/ 


AUTHORIZED   TRANSLATION    FROM    THE   GERMAN 


EDITED   BY 


J.  CHALMERS  DaCOSTA,  M.  D. 

Clinical  Professor  of  Surgery-  in  Jefferson  Medical  College,  Philadelphia; 
Surgeon  to  the  Philadelphia  Hospital,  etc. 


With  24  Colored  Plates  and  217  Illustrations  in  the  Text 


PHILADELPHIA 

W.    B.    SAUNDERS 

925  \Vai,nut  Street 

1898. 


Copyright,  1898, 
By  W.  B.  SAUNDERS. 


'3)oU|=lc<ie   ^.."U^enen.S«..tk  q-^-^O 


eLECTROTYPED    BY  PRESS  OF   W.    B.    SAUNDERS. 

WESTCOTT   &   THOMSON.    PHILADA  .  •? .  PHILADA. 


EDITOR'S  NOTE. 


Pr.  Zuckerkaxdl  requires  no  introduction  to  English- 
speaking  readers.  In  this  Atlas  he  has  laid  down  the 
rules  and  methods  of  surgical  procedure  with  the  clear- 
ness that  springs  from  definite  knowledge  and  the  em- 
phasis that  is  born  of  conviction.  He  describes  lucidly 
and  tersely  the  operations  of  modern  surgery,  and  in  a 
manner  that  fits  the  book  to  be  a  guide  to  the  surgeon 
who  operates  upon  the  living  or  to  the  student  who  works 
upon  the  cadaver,  the  verl^al  descriptions  being  reinforced 
and  illuminated  by  a  large  number  of  excellent  original 
cuts. 

The  aim  of  the  translator  has  been  to  portray  the  spirit 
rather  than  the  exact  words  of  the  author. 

In  a  very  few  places  the  editor  has  added  notes  that 
are  explanatory  in  their  nature,  and  are  not  to  be  con- 
sidered as  portions  of  the  text. 

3 


PREFACE. 


This  epitome  of  operative  surgery  is  intended  as  an 
elementary  work  for  students  in  this  subject.  For  this 
reason  those  groups  of  operations  whose  practice  upon  the 
cadaver  forms  the  basis  of  practical  instruction  are  de- 
scribed in  detail  and  illustrated  in  their  most  conspicuous 
aspects.  Other  operations^  whose  performance  falls 
larcrelv  to  the  lot  of  the  skilled  suro^eon,  and  Avhose 
practice  upon  the  cadaver  appears  less  important,  are 
described  conciselv.  I  am  indebted  to  my  collaborators, 
Mr.  B.  Keilitz,  artist,  and  Mr.  M.  Silbermark,  student  of 
medicine,  for  the  care  that  they  have  given  to  the  illus- 
trative portion  of  the  book.  The  former  has  supplied  the 
colored  plates  and  the  autotypes  in  the  text ;  the  latter 
has  rendered  material  assistance  in  the  execution  of  photo- 
graphs, Avhich  have  been  reproduced  as  wood-cuts,  as  well 
as  in  the  preparation  of  anatomic  specimens. 

The  Althor. 


DESCRIPTION    OF   PLATES. 


Plate 

1. 

Plate 

2. 

Plate 

3. 

Plate 

4. 

Plate 

5. 

Plate 

6. 

Plate 

7. 

Plate 

8. 

Plate 

9. 

Plate 

10. 

Plate 

11. 

Plate 

12. 

Intestinal  suture. 

Exposure  of  brachial'and  axillary  arteries. 

Exposure  of  cubital,  radial,  and  other  arteries. 

Exposure  of  the  femoral  artery  beneath  Poupart's  ligament, 

and  also  at  the  middle  of  the  thigh. 
Exposure  of  the  femoral  artery  in  the  adductor  canal. 
Exposure  of  the  popliteal  arterj'. 

Exposure  of  the  anterior  and  posterior  tibial  arteries. 
Transverse  division  of  the  leg. 
Transverse  division  of  the  thigh. 
Transverse  division  of  the  forearm. 
Transverse  division  of  the  arm. 

Temporary  resection   of    the   lower  jaw  by  the   method  of 
Langenbeck. 
Plate  13.  Laryngofissure. 
Plate  14.  Inferior  tracheotomy. 

Infrahyoid  pharyugotomy. 

Exposure  of  the  common  carotid  artery  and  of  the  subclavian 

artery  below  the  clavicle. 
Exposure  of  the  lingual  artery. 
Topography  of  the  supraclavicular  triangle. 
Formation  of  a  gastric  fistula  through  the  abdominal  wall 
(gastrostomy) ;  establishment  of  a  preternatural  anus  (colos- 
tomy). 
Plate  20.  Union  of  divided  intestine  by  means  of  the  Murphy  button. 
Plate  21.  View  of  the  interior  of  the  bladder  after  suprapubic  cystotomy 

in  Trendelenburg's  position. 
Plates  22,  23.  Radical  operation  for  inguinal  hernia  by  the  method  of 

Bassini. 
Plate  24.  Exposure  of  the  external  iliac  artery. 

5 


Plate  15 
Plate  16, 

Plate  17 
Plate  18 
Plate  19 


DESCRIPTION  OF   FIGURES. 


Figs.  1-7.  Knives  of  various  Ivinds. 

Fig.  8.  Pen-like  mode  of  boldiiig  the  knife. 

Fig.  9.  Violin-bow  mode  of  holding  the  knife. 

Fig.  10.  Division  of  a  raised  fold  of  skin  with  a  sharp-pointed  knife. 

Fig.  11.  Mode  of  holding  and  using  the  resection-knife. 

Figs.  12,  13.  Mode  of  holding  and  using  the  tenotome. 

Fig.  14.  Incision  upon  the  grooved  director. 

Fig.  15.  Mode  of  using  the  blunt-pointed  knife. 

Fig.  Hi.  Dissection  between  two  pairs  of  forceps. 

Fig.  17.  Division  with  scissors. 

Fig.  18,  Mode  of  liolding  the  trocar. 

Fig.  19.  The  thermocautery. 

Fig.  20.  The  wire  snare. 

Fig.  21.  Ecraseur. 

Fig.  22.  The  arched  saw. 

Fig.  23.  The  chain -saw. 

Fig.  24.  The  circular  saw. 

Figs.  25-28.  Suture  of  wounds. 

Fig.  29.  Surgical  needles. 

Fig.  30.  Purse-string  suture. 

Fig.  31.  Mode  of  introducing  the  needle. 

Figs.  32-35.  Various  kinds  of  tendon-suture. 

Fig.  36.  Bone-suture. 

Fig.  37.  Bone-clamp. 

Fig.  38.  Metallic  nails. 

Fig.  39.  Artery  divided  between  two  ligatures. 

Figs.  40-42.  Varieties  of  knots. 

Fig.  43.  Cutaneous  incision  for  ligating  the  axillary  and   brachial 

arteries. 

Fig.  44.  Musculature  of  the  upper  extremity. 

Fig.  45.  Cutaneous  incisions  for  ligating  the   cubital,   radial,  and 

ulnar  arteries. 

Fig.  40.  Phlebotomy. 


8  DESCBIPTIOX  Of  FIGURES. 


Musculature  of  the  thigh. 

Cutaneous  incisions  for  ligating  the  femoral  artery. 

Musculature  of  the  leg,  posterior  aspect. 

Cutaneous  incisions  for  ligating  the  jtopliteal  artery. 

Musculature  of  the  leg,  anterior  aspect. 

Cutaneous  incision  for  ligating  the  anterior  and  posterior 
tibial  arteries. 

Auji)Utation  by  the  circular  incision  in  two  stages. 

Formation  of  a  musculotegumentary  flap  by  transfixion. 

Formation  of  tegumeutary  flaps. 

Circular  incision  after  formation  of  two  musculotegu- 
mentary flaps. 

Oval  incision. 

Suture  of  the  wound  after  amputation. 

Circular  incision,  flap-incision,  for  amputation  of  the  leg. 

Incision  for  amputation  of  the  leg  by  the  method  of  Heine. 

Diagrammatic  representation  of  amputation  of  the  leg 
by  the  method  of  Bier. 

Amputation  by  the  method  of  Syme. 

Amputation  by  the  method  of  Pirogoflf. 

Direction  of  the  sawed  surfaces  iu  Pirogofi^s  operation  and 
its  modifications. 

Achillot^notomy. 

Amputation  of  all  the  toes  through  the  metatarsus. 

Lisfranc's  articular  line. 

Exarticulation  by  the  method  of  Lisfranc. 

Chopart's  articular  line. 

Exarticulation  of  the  foot  below  the  astragalus. 

Cutaneous  incisions  for  exarticulation  at  the  knee-joint. 

Diagrammatic  representation  of  Gritty's  operation. 

Diagrammatic  representation  of  Ssabanajefi"s  operation. 

Amputation  of  the  thigh  by  the  method  of  Gritty. 

Wound  left  by  Ssabauajeflf's  operation. 

Exarticulation  at  the  hip-joint.     Cutaneous  incision. 

Enucleation  of  the  fingers. 

Exarticulation  of  the  hand.     Circular  incision. 

Exarticulation  of  the  hand.     Flap-incision. 

Enucleation  of  the  hand.     Opening  of  the  wrist-joint. 

Enucleation  of  the  hand.     Formation  of  a  jilantar  flap. 

Amputation  of  the  forearm.     Cutaneous  incision. 

Enucleation  at  the  elbow-joint.     Cutaneous  incision. 

Amputation  of  the  arm.     Circular  incision. 


Fi 

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F 

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Fi 

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Fi 

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F] 

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Fi 

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54. 

Fi 

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55- 

58. 

Fi 

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.  59, 

60. 

Fi 

g- 

61. 

F] 

g- 

62. 

F] 

g- 

63. 

Fi 

.64, 

65. 

Fi 

g- 

66. 

Fi 

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.67, 

QS. 

Fi 

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69. 

F 

70. 

Fi 

gs 

.71- 

i  I . 

F 

gs 

.  78-80. 

F 

gs 

.81, 

82. 

F 

or 

83. 

F 

gs 

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85. 

F 

gs 

.86-88. 

F 

or 

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F 

igs 

.90-92. 

F 

or 

93. 

F 

cr 

94. 

F 

95. 

F 

Igs 

.  96-98. 

F 

99. 

F 

or 

100. 

F 

.  101 

-104 

F 

105. 

F 

igs 

.  10€ 

,107 

F 

or 

108. 

F 

cr_ 

109. 

F 

cr_ 

110. 

F 

or 

111. 

F 

Ig- 

112. 

DESCRIPTIOy  OF  FIGURES.  9 

Figs.  113,  lit.  ,Flap-incisions  for  amputation  and  enucleation  of  the  arm. 

Fig.  115.  Kxarticulutiun  of  the  shouhier.     Formation  of  an  axillary 

musculocutaneous  flap. 

Figs.  116,  117.  Exarticulatiou  of  the  shoulder  by  the  method  of  Esmarch. 

Fig.  118.  Resection  of  the  shoulder.     Cutaneous  incision. 

Figs.  119. 120.  Resection  of  the  shoulder  by  the  method  of  I^mgenbeck. 

Fig.  121.  Resection  of  the  elbow -joint.   Situation  of  the  ulnar  nerve. 

Figs.  122  124.  Incisions  for  resection  of  the  elbow-joint. 

Fig.  125.  Resection  of  the  elbow-joint.     Exposure  of  the  constitu- 

ents of  the  jowit. 

Figs.  126. 127.  Resection  of  the  wrist-joint.     Dorsoradial  incision. 

Fig.  12S.  Resection  of  the  hip-joint.     Cutaneous  incision. 

Figs.  129,  130.  Resection  of  the  knee-joint.  Anterior  arched  incision  by 
the  method  of  Textor. 

Fig.  131.  Suprapatellar  incision  by  the  method  of  Hahn. 

Fig.  132.  Resection  of  the  ankle-joint.     Bilateral  longitudinal  inci- 

sion, by  the  method  of  Konig. 

Figs.  1.33-135.  Resection  of  the  ankle-joint  by  the  method  of  Reverdin- 
Kocher. 

Figs.  136-13S.  Resection  of  the  foot  by  the  method  of  Wladimiroff- 
Mikulicz. 

Figs.  139.  140.  Temporary  resection  of  the  skull. 

Fig.  141.  Trephine-situation  for  exposure  of  the  meningeal  artery. 

ligs.  142-144.  Resection  of  the  upper  jaw. 

Figs.  145,  146.  Resection  of  the  lower  jaw. 

Fig,  147.  Temporary  resection  of  the  lower  jaw  by  the  method  of 

Sedillot. 

Fig.  148.  Submental  extirpation  of  the  tongue  by  the  method  of 

Billroth. 

Fig.  149.  Cutaneous  incision  for  extirpation  of  the  tongue  by  the 

method  of  Kocher. 

Figs.  1.50, 151.  Wedge-shaped  excision  of  the  lower  lip.    Suture. 

Figs.  152, 153.  Clieiloplasty  by  the  method  of  Dieffenbach. 

Figs.  154, 155.  Cheiloplasty  by  the  method  of  Langenbeck. 

Figs.  156-15"-:.  Rhinoplasty  with  the  skin  of  the  forehead. 

Figs.  159.  160.  Partial  rhinoplasty. 

Figs.  161-163.  Xelaton's  operation  for  cleft  palate. 

Figs.  164-166.  Malgaigne's  operation  for  cleft  palate. 

Figs.  167-169.  Mirault-Langenbeck's  operation  for  cleft  palate. 

Figs.  170-172.  Operation  for  bilateral  cleft  palate. 

Fig.  173.  Incisions  for  the  relief  of  tension  after  extensive  division 

of  the  lip. 


10  DESCRIPTION  OF  FIGURES. 

Fig.  174.  Exposure  of  the  frontal  nerve. 

Fig.  175.  Exposure  of  the  infra-orbital  nerve. 

Fig.  176.  Exposure  of  the  mental  nerve. 

Fig.  177.  Cutaneous  incisions  for  operations  upon  the  air-passages. 

Figs.  178,  179.  Tracheal  cannulae. 

Figs.  180-184.  O'Dwyer's  outfit  for  intubation. 

Fig.  185.  Esophagotomy. 

Fig.  186.  Cutaneous  incisions  for  ligation  of  the  vessels  of  the  neck. 

Fig.  187.  Scalene  opening. 

Fig.  188.  Amputation  of  the  mammary  gland. 

Fig.  189.  Elevation  of  the  pelvis. 

Fig.  190.  Incisions  in  the  abdominal  wall. 

Figs.  191-196.  Varieties  of  catheters  and  sounds. 

Fig.  197.  Introduction   of   a  partially   rigid    instrument  into   the 

bladder. 
Figs.  198, 199.  Introduction  of  a  rigid  instrument  through  the  urethra. 
Figs.  200-203.  Catheterization. 
Fig.  204.  Attachment  of  retention-catheter. 

Figs.  205-207.  Puncture  of  the  bladder. 
Fig.  208.  Suprapubic  cystotomy. 

Figs.  209,  210.  Prostatotomy. 

Figs.  211,  212.  Operation  for  shortened  frenulum. 
Figs.  213,  214.  Plastic  operation  for  urethral  fistula. 
Fig.  215.  Exposure  of  the  constricting  ring  of  an  inguinal  hernia. 

Fig.  216.  Exposure  of  the  kidney. 

Fig.  217.  Invagination-suture  of  the  stumps  of  the  ureters. 


CONTENTS. 


A.  Division  of  the  Tissues. 

PAGE 

Mode  of  holding  the  knife     18 

Dissection  of  the  tissues 26 

Division  with  scissors 34 

Division  of  tissues  by  puncture 38 

Bloodless  method  of  dividing  tissues 39 

Division  of  bone 41 

B.  Reunion  of  the  Tissues. 

Suture  of  wounds 44 

Suture  of  muscles 49 

Suture  of  tendons      49 

Suture  of  nerves 51 

Suture  of  bones 52 

Intestinal  suture 53 

Suture  of  the  bladder 55 

I.  Operations  on  the  Extremities. 

1.  Ligation  of  Vessels  in  Continuity. 

Indications 57 

General  considerations  upon  performance  of  ligations 58 

Ligations  in  the  upper  extremities 62 

Ligation  of  the  axillary  artery 63 

Ligation  of  the  brachial  artery 65 

Ligation  of  the  cubital  artery 66 

Ligation  of  the  radial  and  ulnar  arteries 70 

Ligations  in  the  lower  extremities 74 

Ligation  of  the  femoral  artery 74 

1.  L'nder  Poupart's  ligament 75 

2.  In  the  middle  of  the  thigh ....  75 

3.  In  Hunter's  canal 77 

11 


12  coy  TEXTS. 

PAGE 

Ligation  of  the  saphenous  vein 77 

Ligation  of  the  popliteal  artery 77 

Ligation  of  the  anterior  and  posterior  tibial  arteries 80 

2.  Amputations  and  Enucleations. 

Indications 86 

General  considerations  upon  amputations 87 

Circular  incision 88 

Flap-amputations 96 

Oval  incision 108 

Division  of  the  bone 108 

Amputations   and  Exarticulations  of   the   Lower   Extremity. 

Amputation  of  the  leg 112 

Syme's  amputation 113 

Pirogoff's  amputation  of  the  foot 120 

Achillotenotomy 132 

Exarticulations  and  Amputations  in  the  Eegion  of  the  Foot. 
Exarticulations  through  the  interphalangeal  or  metatarsophalangeal 

joints 132 

Amputation  of  all  toes  through  the  metatarsus 137 

Esarticulation  of  the  great  toe  with  the  metatarsus 138 

Exarticulation  through  the  tarsometatarsal  joints  by  the  method  of 

Lisfranc 139 

Intertarsal  amputation 146 

Intertarsal  exarticulation  (Chopart) 149 

Subastragaloid  enucleation  iMalgaigne) 150 

Exarticulation  of  the  leg  at  the  knee-joint 153 

Amputation  of  the  thigh 154 

Circular  incision  in  two  stages 155 

Flap-formation 156 

Osteoplastic  supracondylar  amputation  of  the  tliigh  by  the  method 

of  Gritty 161 

Osteoplastic  supracondylar  amputation  of  the  thigh  by  the  method 

of  Ssabanajeff 162 

Exarticulation  at  the  hip-joint 163 

Exarticulation  at  the  hip-joint  by  the  method  of  Esmarch  .  .  .  163 
Exarticulation  at  the  hip-joint,  with  the  formation  of  two  musculo- 

tegumentary  flaps  by  transfixion 163 


CONTENTS.  13 

Amputations  and  Exarticulations  of  the  Upper  Extremity. 

PAGE 

Exarticulations  of  the  fingers  throuj;h  the  iuterphalangeal  joints; 

through  tlie  nietacarpophahmgeal  joints 167 

Exarticuhition  of  the  little  finger  through  the  metacarpus  by  the 

method  of  Walther 109 

Amputation  of  a  finger  through  the  metacarpus 174 

Exarticulations  at  the  wrist 175 

Enucleation  'of  the  hand  by  means  of  a  circular  incision  and  the 

formation  of  a  cuff 170 

Enucleation  of  the  hand  by  means  of  anterior  and  posterior  cuta- 
neous flaps 181 

Amputation  of  the  forearm   .    ,    .    : 181 

Enucleation  at  the  elbow-joint 182 

Amputation  of  the  arm 184 

Exarticuhition  of  the  humerus 185 

Deltoid  musculotegumentarj'^  flaps  . 186 

Oval  incision  by  the  method  of  Esmarch 188 

3.  Resections  at  the  Joints  of  the  Extremities. 

General  considerations  upon  resection  of  the  joints 191 

Indications 192 

Eesections  of  the  Joints  of  the  Upper  Extremity. 

Resection  of  the  shoulder-joint  by  the  method  of  Langenbeck  .  .  193 
Resection  of  the  elbow-joint  by  the  method  of  Langenbeck  .  .  .  199 
Resection  of  the  elbow-joint  by  the  method  of  Kocher 205 

Resection  of  the  Wrist- joint. 
Resection  of  the  joints  of  the  hand  by  the  method  of  Langenbeck  .    205 

Resections  of  the  Joints  of  the  Fingers. 
Resection  at  the  metacarpophalangeal  joint 206 

Resections  of  the  Joints  of  the  Lower  Extremity. 

Resection  of  the  hip-joint .  207 

Resection  of  the  hip-joint  by  the  method  of  Langenbeck      ....  207 

Resection  of  the  hip-joint  by  the  method  of  Velpeau 207 

Resection  of  the  knee-joint 209 

Resection  of  the  ankle-joint  by  the  method  of  Langenbeck  ....  211 

Resection  of  the  ankle-joint  by  the  method  of  Konig 213 

Resection  of  the  ankle-joint  by  the  method  of  Reverdin-Kocher     .  214 


14  CONTENTS. 

PAGE 

Resection  of  the  aakle-joiut  by  the  method  of  Wladimiroff-Miku- 

licz 214 

Osteotomy .  218 

Osteotomy  of  the  femur 221 

II.  Operations  on  the  Head  and  Neck. 

Trephining. 

Indications  foi*  trephining 223 

Osteoplastic  resection  of  the  skull 225 

Resections  of  the  Jaws. 

Resection  of  the  upper  jaw 229 

Temporary  resection  of  the  upper  jaw 233 

Resection  of  the  lower  jaw 234 

Temporary  resection  of  the  lower  law 239 

Median  division  of  the  lower  jaw       ....        240 

Lateral  division  of  the  lower  jaw 240 

Opeeations  on  the  Tongue. 

Submental  extirpation  of  the  tongue 251 

Extirpation  by  the  method  of  Kocher 251 

Plastic  Operations, 

General  considerations 252 

Rhinoplasty 254 

Operation  for  saddle-nose 256 

Plastic  correction  of  defects  of  the  cheek 259 

Operations  for  harelip 260 

Staphylorrhaphy  and  uranoplasty 265 

Operations  on  the  Nerves  of  the  Head. 

First  (ophthalmic)  division  of  the  trigeminus 267 

Second  (superior  maxillary)  division  of  the  trigeminus 267 

Third  (inferior  maxillary)  division  of  the  trigeminus 269 

Exposure  of   the  superior  and  inferior  maxillary  branches  by  the 

method  of  Kronlein      272 

Exposure  of  the  inferior  maxillary  division  at  the  base  of  the  skull  .  273 

Intracranial  operations  on  the  trigeminus 274 

Operations  on  the  Air-passages. 

Laryngotomy 275 

Cricothyrotomy • 276 


COyi'ENTS.  15 

PAGE 

Extirpation  of  the  larynx 277 

Tracheotomy 278 

lutubatiou 284 

Pharyngotomy 287 

Esophagotomy        288 

Ligations  of  the  Vessels  in  the  Region  op  the  Neck. 

Ligation  of  the  iimoniinate  artery 291 

Ligation  of  the  common  carotid  artery 292 

Ligation  of  the  external  carotid  artery     292 

Ligation  of  the  superior  thyroid  artery 294 

Ligation  of  the  lingual  artery      295 

Ligation  of  the  subclavian  artery 295 

(a)  Above  the  clavicle 297 

(b)  Below  the  clavicle 298 

Ligation  of  the  inferior  thyroid  artery 299 

Operations  for  goiter 299 

III.  Operations  upon  the  Trunk  and  the  Pelvis. 

Paracentesis  thoracis 302 

Thoracotomy      303 

Ligation  of  the  internal  mammary  artery 304 

Amputation  of  the  breast 304 

Abdominal  puncture 307 

Celiotomy           308 

Operations  upon  the  Stomach  and  the  Intestines. 

Formation  of  a  gastric  fistula  ;  gastrostomy 311 

Formation  of  an  intestinal  fistula  ;  enterostomy 313 

Formation  of  a  preternatural  anus 313 

Eesection  of  the  bowel 315 

Exclusion  of  the  bowel 317 

Gastro-enterostomy      318 

Operations  upon  the  Biliary  Apparatus. 

Operations  upon  the  gall-bladder      319 

Operations  upon  the  cecum  and  upon  the  vermiform  appendix     .    .    321 

Operations  upon  the  Urinary  Organs. 

Catheterization 322 

Puncture  of  the  bladder 3.3fi 

External  urethrotomy 337 


16  COSTEyTS. 

PAGE 

External  urethrotomy  with  a  guide 340 

External  urethrotomy  without  a  guide      340 

External  urethrotomy  in  the  presence  of  rupture  of  the  urethra  .    .  342 

Internal  urethrotomy 343 

Lateral  section , 344 

Median  section 344 

Urethrostomy 345 

Litholapaxy 345 

Suprapubic  section        347 

1.  High  incision  for  stone 348 

2.  High  incision  for  the  performance  of  endovesical  operations    .  349 

3.  High  cystostomy 350 

Operations  upon  the  Pkostate,  the  Seminal  Vesicles,  and 
THE  VAS  Deferens. 

Prostatotomy 355 

Extirpation  of  the  seminal  vesicles 356 

Prostatectomy 356 

Eesection  and  excision  of  the  vas  deferens 357 

Extirpation  of  the  testicle      358 

Operation  for  hydrocele 359 

Operation  for  phimosis 360 

Amputation  of  the  penis 362 

Urethral  fistulse     363 

Operations  for  Hernia. 

Herniotomy 364 

Eadical  operation 367 

(a)  For  inguinal  hernia 367 

(b)  For  femoral  hernia 371 

(c)  For  umbilical  hernia 371 

Ligation  of  the  iliac  artery 372 

Operations  upon  the  Kidneys. 

Nephrotomy  and  Nephrectomy 374 

Operations  upon  the  ureters 377 

Operations  upon  the  Rectum  and  the  Anus. 

Amputation  and  resection  of  the  rectum 379 

Operation  for  anal  fistula 382 

Operation  for  hemorrhoids 383 

Operation  for  atresia  ani 384 


OPERATIVE    SURGERY. 


GENERAL   CONSIDERATIONS. 

(A)  Division  of  the  Tissues. 

The  soft  parts  raav  be  divided  by  either  bloody  or 
bloodless  means  :  by  bloody  means,  with  the  knije  or  the 
scissors  or  by  puncture ;  by  bloodless  means,  with  the 
actual  caiUery,  the  glowing  or  the  cold  wire-loopy  the  elas- 
tic ligature,  and  the  ecraseur. 

Bones  may  be  divided  either  with  chisel  and  mallet j 
with  the  saw,  with  bone-shearSy  or  bone-forceps,  or  with 
appropriate  apparatus  in  special  situations  (osteoclasis). 

The  most  important  and  the  most  generallv  used  in- 
strument of  the  surgeon,  the  hnife,  consists  of  a  blade 
and  a  handle,  which  are  either  made  of  one  piece  or  are 
articulated  by  means  of  an  adjustable  joint. 

In  accordance  with  the  form  of  the  blade  the  following 
varieties  of  knives  are  recognized  : 

The  bellied  scalpel ; 

The  sharp-pointed  knife ; 

The  blunt-pointed  knife. 

In  the  bellied  scalpel  (Fig.  3)  the  cutting-edge  is  con- 
vex, and  the  back  straight  and  continuous  with  the  handle 
of  the  knife. 

The  sharp-pointed  knife  is  convex  upon  its  back  as  well 
as  upon  its  cutting-surface,  terminating  in  a  sharp  point 
(Fig.  2). 

The  blunt-pointed  hnife  is  provided  with  a  peripheral 
button-like  extremity  (Fig.  1). 

2  17 


18  OPERATIVE  SURGERY. 

Fig.  1. — Blunt-pointed  knife. 

Fig.  2. — Sharp-pointed  knife  (sharp-pointed  bistoury). 

Fig.  3. — Simple  bellied  scalpel. 

Fig.  4. — Resection-knife. 

Fig.  5. — Amputation-knife. 

Fig.  6. — Tenotomes,  with  convex  and  concave  cutting-edges. 

Fig.  7. — Blunt-pointed  bistoury. 

In  accordance  with  the  size  and  construction  of  knives 
further  distinctions  are  made  of  amputation-knives  (Fig. 
5),  resection-knives  (shorty  strong  knives,  Fig.  4),  tenotomes 
(Fig.  6),  etc. 

Division  of  tissues  vnth  the  knife  is  eflPected  by  a  combi- 
nation of  pressure  and  traction^  the  proper  amount  of 
each  force  employed  being  a  matter  or  experience.  Be- 
ginners often  err  in  exercising  only  pressure  with  the 
cutting-edge  of  the  knife. 

For  the  division  of  the  skin  from  the  surface  a  simple 
bellied  scalpel  is  used.  This  is  grasped  between  the 
thumb,  the  index  and  the  middle  finger  like  a  pen,  the 
uhiar  border  of  the  little  finger  resting  upon  the  opera- 
tive surface,  while  the  tissues  to  be  divided  are  made 
tense  with  the  fingers  of  the  left  hand  (Fig.  8).  This  is 
the  mode  of  holding  the  knife  in  making  small  cutaneous 
incisions  and  in  free  dissection  of  the  tissues. 

In  making  incisions  of  greater  length  the  knife  is  held 
between  the  thumb  and  the  pulps  of  the  four  fingers  like 
a  violin-bow,  the  tissues  to  be  divided  being  made  tense 
with  the  left  hand.  The  operating  hand  is  held  free, 
without  any  support  whatever  (Fig.  9). 

If  the  knife  is  to  be  carried,  with  a  single  stroke, 
through  a  thick  layer  of  soft  structures  dow^n  to  the  bone, 
as,  for  instance,  in  exposing  a  joint,  it  is  held  like  a  table- 
knife  and  pushed  through  the  soft  tissues  (Fig.  11). 
The  division  is  effected  by  a  sawing  movement  of  the 
knife. 

For  the  subcutaneous  division  of  tendons  the  tenotome 
is  grasped  either  between  the  thumb,  the  index  and  the 
middle  finger  (Fig.  12),  or  as  an  ordinary  knife  is  held 


DfVISIOy  OF  THE  TISSUES. 


19 


Fig.  1.      Fig.  2.      Fig.  3.      Fig.  4. 


I 


Fig.  5. 


Fig.  6. 


Fig.  7. 


DIVISIOJ^  OF  THE  TISSUES. 


21 


DlVl^lO^   OF  THE  TISSUES. 


23 


DIVISION  OF  THE  TISSUES. 


26 


in  parin<i"  fruit,  witiiin  four  fingers,  while  the  thumb  is 
su|)|)(»rt('(l   upon  tlie  operative  surfaee  (Fi^'.   13). 

11"  tile  skin  is  to  be  divided  from  within  outward,  a 
sharp-pointed  knife  is  used,  which  is  passed  at  right 
angles  through  the  base  of  a  raised  fold  of  skin  and 
earried  toward  the  skin  (Fig.   10). 

If  a  circular  incision  through  the  skin  in  the  entire 
periphery  of  a  part  is  to  be  made — for  example,  around 
the  ankle — the  knife  is  'grasped  within  the  w^hole  fist, 
with  the  cutting-edge  applied  at  right  angles  upon  the 
skin  covering  the  surface  of  the  extremity  opposite  to  the 
side  upon  which  the  operator  stands,  being  carried  around 


Fig.  10. — Division  of  a  raised  fold  of  skin  from  base  to  surface. 

the  extremity  according  to  rules  that  will  receive  dis- 
cussion later  (see  page  88). 

In  general,  cutaneous  incisions  should  sever  the  skin 
vertically.  Oblique  division  of  the  skin  is  indicated  only 
in  certain  cases. 

Cutaneous  incisions,  in  accordance  wdth  their  form,  are 
either  linear,  semilunar,  tongue-shaped  (flap),  T-shaped, 
H-shaped,  or  I-shaped,  trapdoor-like,  anchor-shaped  (J^), 
etc. 

The  length  of  the  incision  varies  in  accordance  with 
the  depth  to  which  access  is  desired.  In  general,  cuta- 
neous incisions  should  not  be  too  small,  as  longer  inci- 


26 


OPERATIVE  SURGERY. 


sions  permit  careful  in.speetion  of  deep-seated  structures, 
and  are  thus  more  convenient  and  also  more  conservative. 
Deep  Dissection. — Accurate  surgical  dissection  con- 
sists in  attaining  tlie  desired  end,  the  exposure  or  the 
enucleation  of  a  structure,  with  most  complete  protection 
possible  of  adjacent  tissues.     Structures  that  obstruct  the 


Fig.  11. — Mode  of  using  the  resection-knife. 

field  of  operation  may  be  displaced  by  means  of  retractors 
or  tenacula  (blunt,  sharp,  with  one  or  more  teeth) ;  nerves 
and  vessels  should  never  be  held  between  the  blades  of 
forceps,  but  should  always  be  carefully  dis])laced  with 
the  aid  of  blunt  retractors.  If  a  blood-vessel  be  in  the 
way,  it  may  be  secured  with  two  ligatures  and  divided 


DIVISION  OF  THE  TISSUES. 


21 


Fig.  12.— Mode  of  using  the  tenotome. 


DIVISION  OF  THE  TISSUES. 


29 


DIVISKjy  OF  THE  TISSUES. 


31 


DIVISION  OF  THE  TISSUES.  33 

lu'twocn  these.     In  order  to  practise  deep  dissection  safely 
several  methods  may  he  pnrsued  : 

(1)  Free  dissection, 

(2)  Dissection  with  the  aid  of  the  grooved  director, 
^3)  Dissection  between  two  pairs  of  forceps, 

(4)  Blunt  dissection. 

Free  dissection  with  the  scalpel  requires  anatomical  cer- 
tainty and  skill  in  the  use  of  the  knife,  which  is  held  like 
a  pen. 

Dissection  with  the  aid  of  the  grooved  director  is  to  be 
recommended  when  in  the  course  of  operation  the  anatom- 
ical relations  permit  the  tissues  to  be  separated  layer  by 
layer.  It  is  applicable  in  the  performance  of  herniotomy, 
in  the  open  operation  for  hydrocele,  in  division  of  the 
abdominal  walls,  etc.  With  a  pair  of  anatomic  forceps 
held  in  the  left  hand  a  small  cone  of  the  tissue  to  be 
divided  is  raised  up  and  slit  open  at  its  base  w  ith  a  knife. 
Through  the  opening  thus  made  a  grooved  director  is 
introduced,  with  its  groove  directed  upward,  and  pointed 
in  the  direction  of  the  proposed  incision.  The  groove  of 
the  director  serves  as  a  guide  for  the  back  of  the  knife  in 
making  the  incision  (Fig.  14).^ 

In  operating  between  tico  pairs  of  forceps  the  operator 
and  his  assistant  pick  up  successively  the  tissues  to  be 
divided  at  opposite  points,  and  the  fold  of  skin  thus 
raised  is  incised  between  the  two  instruments  (Fig.  16). 
This  mode  of  procedure  is  applicable  in  opening  the 
abdominal  cavity  and  in  the  performance  of  herniotomy. 

Blunt  dissection  for  the  isolation  of  structures  in  loose 
cellular  tissue  is  accomplished  by  pushing  the  tissues  back 
with  two  pairs  of  anatomic  forceps  and  thus  avoiding 
hemorrhage.  This  method  is  especially  indispensable  in 
the  exposure  of  vessels  and  nerves  and  of  the  trachea.^ 

If  a   considerable  layer  of  muscular  tissue   is   to   be 

^  It  is  rarely  advisable  to  use  a  grooved  director.  It  lacerates  parts, 
gives  irregular  incisions,  and  hence  militates  against  primary  union.  A 
surgeon  rarely  finds  the  instrument  necessary. — Ed. 

2  In  accomplishing  blunt  dissection  the  Allis  dissector  is  of  the  greatoet 
value. — Ed. 


34  OPERATIVE  SURGERY. 

divided  with  the  first  incision,  a  strong,  short,  resection- 
knife  is  used.  This  is  grasped  like  a  table-knife,  and 
pushed  vigorously  through  the  soft  structures  down  to 
the  bone,  when  with  sawing  movements  thick  layers  of 
muscle  may  be  divided  (Fig.  11). 

For  circular  division  of  masses  of  muscle  the  knife  is 
held  within  the  whole  fist  and  used  according  to  certain 
rules  (see  page  95). 

If  a  band  in  the  depth  of  the  wound  and  not  accessible 
to  the  eye,  or  a  constricting  ring,  is  to  be  divided,  this  is 
usually  effected  by  means  of  the  blunt  knife  or  herniotome 
under  guidance  of  the  finger.  The  blunt  point  protects 
the  tissues  from  injury  when  the  knife  is  introduced,  as 


.    Fig.  15. — Mode  of  using  the  blunt-pointed  knife. 

well  as  the  pulp  of  the  left  index-finger,  upon  which  the 
knife  is  supported.  After  the  precise  point  at  which  the 
incision  should  be  made  has  been  determined  by  means  of 
the  introduced  index-finger,  the  blunt-pointed  knife  is 
grasped  like  a  pen  and,  Avith  its  back  supported  upon  the 
palmar  surface  of  the  index-finger,  is  introduced  into  the 
depth  of  the  wound.  The  division  is  effected  through  the 
pressure  exerted  by  the  finger  upon  Avhich  the  knife  is 
resting  (Fig.  15). 

Division  with  Scissors. — The  scissors  is  used  for 
the  division  of  strand-like  structures,  tendons,  muscles, 
vessels ;  also  certain  structures  that  on  account  of  their 
consistency  are  unsuitable  for  division  with  the  knife,  as, 


DIVISION  OF  THE  TISSUES. 


35 


DIVISION  OF  THE  TISSUES. 


37 


for  instance,  the  yiokling  intestinal  tissues  when  resected 
are  divided  bv  tlie  .-^cIshu's.  The  scissors  may  also  be 
used  alternately  with  a  knil'e  in  the  dissection  of  tissues 
in  the  process  of  enucleating  structures.^  The  blunt 
bhide  of  the  scissors  is  introduced  beneath  the  layer  of 
tissues  to  be  divided. 

Scissors  with  straight  blades  or  scissors  curved  u])on 
the  flat  are  employed.     In  using  the  scissors  the  thumb 


^  'iMMtl 


Tjl 


J^^^si 


Fio.  17. — Division  with  scisson 


and  the  middle  finger  are  introduced  into  the  rings  of  the 
handles  and  the  index-finger  is  placed  upon  the  lock 
(Fig.  17). 

The  tissnes  to  be  divided  are  caught  between  the 
blades  of  the  scissors,  division  being  effected  by  the 
movement  of  the  blade  held  by  the  thumb  against  the 
other,  Avhich  is  grasped  firmly. 

^  The  scissors  are  very  useful  iu  enucleating  dermoid  cysts,  sebaceous 
cysts,  adherent  fatty  tumors,  ])ursee,  and  fibromata. — Ed. 


38  '  OPERATIVE  SURGERY. 

Division  of  Tissues  by  Puncture. — Division  of 
tissues  by  puncture  is  practised  when  fluid  is  to  be  evacu- 
ated through  a  cannuUi  introduced  into  pathological  or 
physiological  cavities  (puncture  of  abscesses,  of  hydro- 
cele) ;  or  when  a  sharp,  hollow  needle  is  employed  to 
introduce  fluid  into  the  cellular  tissue  or  into  the  paren- 
chyma of  organs  (subcutaneous,  parenchymatous  injec- 
tions). Exploration  with  the  introduced  needle  is  at 
times  necessary  for  diagnostic  purposes  in  the  depth  of 
the  tissues.  Finally,  in  the  introduction  of  sutures, 
puncture-canals  are  necessary. 

For  puncture,  straight  or  curved  tubular  instruments 
(trocars)  are  required,  which  are  provided  with  a  stilet, 
w^hose  sharp  extremity  projects  a  slight  distance  beyond 


fc: 


Fig.  18. — Mode  of  using  a  trocar. 


the  end  of  the  tube.  In  making  a  puncture  the  trocar  is 
so  held  in  the  full  fist  that  the  instrument  rests  in  the 
hollow  of  the  hand,  the  index-finger  marking  the  point 
upon  the  shaft  to  which  it  may  enter  (Fig.  18). 

With  a  vigorous  push  the  instrument  is  forced  vertically 
through  the  skin  in  the  selected  situation  and  into  the 
cavity.  The  entrance  of  the  trocar  into  the  cavity  is  indi- 
cated by  a  change  in  the  sense  of  resistance.  The  cannula 
is  now  grasped  at  its  extremity  with  the  thumb  and  the 
index-finger  of  the  left  hand  and  the  trocar  is  with- 
drawn. 

Puncture  made  wath  slender  instruments  for  diagnostic 
purposes  is  known  as  exploratory  puncture.  The  escape 
of  the  contents  through  the  slender  tube  of  the  cannula 


DIVISION  OF  THE  TISSUES. 


39 


must  often  be  aided  by  iispiratinn  by  means  of  an  attached 
syringe.' 

For  the  purpose  of  making  .subcutaneous  injections  a 
fold  of  skin  is  raised  and  the  needle  of  the  syringe  is  in- 
troduced horizontally  through  the  skin  into  the  subcu- 
taneous cellular  tissue,  into  whic^h  tlie  fluid  is  forced  by 
pressure  upon  the  piston  of  the  syringe.^  In  making 
parenchymatous  injections  the  needle  of  the  syringe  is 
introduced  directly  through  the  skin  into  the  interior  of 
the  organ  (thyroid  gland,  lymphatic  glands). 


Fig.  19.— The  thermocautery  of  Paquelin  :  A,  tip  ;  li,  spirit-lamp;  C,  rub- 
ber air-bulb  ;  D  E,  reservoir  for  benzine. 

Bloodless  Methods  of   Dividing  Tissues.— (1) 
The  actual  caidery,  consisting  of  an  iron  rod  brought  to  a 

1  The  old  grooved  exploring-needle  has  been  generally  abandoned  in 
favor  of  the  hollow  needle.  The  former  instrument  is  unsafe  if  infective 
material  is  withdrawn  by  it,  as  the  fluid  comes  in  contact  with  the  canal 
of  i)uncture  and  will  probably  infect  it. — Ed. 

■''  After  introducing  the  needle  move  it  from  side  to  side  to  see  tbat  it 
is  free  and  to  be  certain  it  has  not  entered  a  blood-vessel. — Ed. 


40  OPERATIVE  SURGERY. 

glow  in  the  fire,  finds  no  ap])lication  in  this  crude  form  in 


Fig.  20. — Wire  loop  (snare). 


Fig.  21. — Ecraseur. 


modern  surgery,  altliougli  tissues  may  be  divided  Avithout 
loss  of  blood  by  means  of  the  glowing  extremity  of  the 


DIVISION  OF  THE  TISSUES.  41 

thermocauter ij  ot"  Pac|iielin  (Fig.  19),  or  with  a  wire 
brought  to  a  glow  by  means  of  an  electric  current  [gnl- 
vanocautenj).  The  extremity  of  the  thermocautery 
brought  to  a  red  heat  in  tlie  flame  of  an  alcohol-lamp 
may  be  kept  in  a  continuous  glow  by  means  of  a  tine 
spray  of  petroleum-ether.  By  regulating  the  stream  of 
petroleum-ether  vapor — that  is,  by  more  or  less  energetic 
manipulation  of  the  air-Uull)  attached  to  the  apparatus — 
all  degrees  of  incandescence  up  to  white  heat  may  be 
secured. 

By  means  of  the  various  kinds  of  hops  or  snares  tis- 
sues may  be  separated  at  their  base  if  they  be  so  consti- 
tuted that  the  loop  may  be  made  to  surround  the  line  of 
division.  The  galvanoeaustic  snare  brought  to  a  glow  by 
means  of  an  electric  current  and  gradually  tightened 
divides  the  tissues  without  loss  of  blood. 

The  simple  xcire  snare,  which  crushes  directly  through 
the  tissues,  can  only  be  employed  in  the  removal  of  struct- 
ures of  slight  resistance — for  instance,  nasal  polypi.  The 
tightening  of  the  loop  is  effected  by  means  of  a  suitable 
screw-attachment  (Fig.  20). 

The  elastic  ligature  (Dittel),  an  India-rubber  band 
tightly  wrapped  around  the  tissues  to  l)e  divided,  operates 
through  the  continuous  pressure  exerted  and  cuts  its  way 
through  gradually  in  the  course  of  days  or  weeks.  The 
process  is  so  gradual  that  the  surface  exposed  after  sepa- 
ration represents  a  simple  granulating  wound.  The 
elastic  ligature  may  also  be  employed  successfully  in  the 
severance  of  dense  fibrous  pedicles  of  considerable  extent, 
as  in  the  removal  of  some  uterine  myomata. 

Ecrasemeut.  the  crushing  of  tissues  with  the  aid  of  a  linked  chain,  was 
employed  in  large  numbers  of  cases  during  the  middle  of  the  present 
century.  The  ecraseur  of  Chassaignac  (Fig.  21)  permits  of  quite  gradual 
tightening  of  the  chain,  which  is  withdrawn  link  by  link  within  the 
shaft  of  the  instrument.  Ecrasement  has  been  almost  totally  displaced 
by  the  galvanocautery  and  the  thermocautery. 

Division  of  Bone. — This  is  effected  with  the  aid  of 
the  saw,  cliisel  and  mallet,  bone-shears,  and  bone-forceps. 


i2  OPERATIVE  SURGERY. 

Bones  are  broken  subcutoneously  either  manually,  or  with 
the  aid  of  special  apparatus  (osteoclasts). 

Bloody  division  of  bone  should  always  be  preceded  by 
detachment  and  division  of  i\\Q  periosteum  in  the  line  of 
intended  operation. 

The  aiyhed  saw  (Butcher's)  (Fig.  22)  is  used  whenever 
the  conditions  permit  of  free  movement  of  the  instrument, 


Fig.  22. — Arched  saw  (Butcher's). 

as  in  division  of  the  bones  of  the  extremities  in  the  course 
of  amputations  and  of  the  articular  extremities  in  the 
course  of  resections. 

In  the  use  of  the  arched  saw  care  should  be  taken  that 
the  instrument  is  held  accurately  in  the  plane  of  intended 
division.  The  saw  is  first  applied  with  slight,  almost 
with  no,  pressure,  greater  force  being  employed  after  a 


Chain-saw. 


groove  has  been  formed  for  the  blade  of  the  instrument. 
If  the  bone  to  be  divided  is  so  situated  that  free  move- 
ment of  the  arched  saw  is  likely  to  be  interfered  with,  as 
in  division  of  the  lower  jaw,  of  the  zygomatic  process  of 
the  upper  jaw,  etc.,  the  chain-saio  (Fig.  23)  or  the  imre  saw 
may  be  employed  with  advantage.  The  former  consists 
of  a  series  of  toothed  links  united  by  joints,  the  termi- 


DIVISION  OF  THE  TISSUES. 


43 


mil  links  bein^  provided  with  openings  through  whicli  aj)- 
])r()pri:ite  handles  may  he  attached.  I'he  wire  saw  con- 
sists of  a  wire  provided  with  a  regular  sj)iral  tiiread  like  a 
screw,  and  it  is  used  in  the  same  manner  as  the  chain-saw. 
Of  late  it  has  become  customary  to  use  forms  of  circular 
smrs  in  opt^rating  upon  the  bones  of  the  skull.  These  may 
be  driven  by  means  of  foot-j)ower,  or  the  electric  current, 
or  hand-motors  (Fig.  24).  It  is  thought  that  in  employ- 
ing the  circular  saw  in  operations  upon  the  skull  the  con- 


FiG.  24. — Circular  saw  with  hand-motor. 

cussion  resulting  from  the  use  of  the  chisel  and  mallet  is 
avoided. 

Chisel  and  mallet  likewise  may  be  employed  in  opera- 
tions upon  the  bones  of  the  extremities,  as  in  linear  osteot- 
omy, and  in  chiselling  of  necroses,  although  resections 
Avith  the  chisel  are  also  practised  upon  the  bones  of  the 
skull. 

Thin  bony  structures,  as  the  ribs,  phalanges,  projecting 
splinters  upon  sawed  surfaces,  may  be  divided  by  means 
of  bone-shears  or  bone-forceps. 


44  OPERATIVE  SURGERY. 

To  freshen  bone-surfaces  the  sharp  spoon  and  strong 
knives  may  be  used  with  advantage. 

Osteoclasis,  the  breaking  of  bone,  may  be  undertaken 
for  orthopedic  reasons  in  cases  of  badly  united  fractures 
and  of  deformities  of  the  extremities,  either  manually  or 
with  the  aid  of  apparatus  (osteoclasts).  Manual  osteoclasis 
suffers  from  the  disadvantage  that  the  fracture  may  fail  to 
take  place  in  the  desired  situation.  Useful  forms  of  osteo- 
clasts have  been  devised  by  Eizzoli  and  by  Robin.  That 
of  the  latter  is  constructed  upon  the  principle  of  the  one- 
arm  lever,  and  permits  the  breaking  of  the  bone  at  pre- 
cisely the  point  selected,  with  the  slightest  possible  in- 
jury of  the  overlying  soft  structures. 

(B)  Reunion  of  the  Tissues. 

The  reunion  of  tissues  has  for  its  object  the  firm  and 
unyielding  approximation  of  the  several  layers  of  an  exist- 
ing wound  throughout  the  period  of  healing.  Such  ap- 
proximation may  be  effected  shortly  after  the  reception  of 
the  injury  {primary  suture),  or  at  a  time  when  the  wound 
has  entered  upon  the  stage  of  granulation  {secondary 
suture). 

Bloodless  approximation  of  divided  tissues,  skin-wounds, 
by  means  of  adhesive  agents,  such  as  collodion,  adhesive 


Fig.  25. — Simple  knotted  (interrupted)  suture. 

plaster,  is  only  applicable  in  cases  of  exceedingly  slight 
injury,  without  considerable  separation  of  the  margins 
of  the  wound.  .  Wounds  of  greater  extent,  if  capable 
of  primary  union,  should  always  be  closed  by  bloody 
suture. 


REUNION  OF  THE  TISSUES. 


45 


By  moans  of  curved  needles  (Fig.  29,  (t  and  />)  threads 
arc  passed  tliroiioli  tlie  lips  ut*  the  wound  and  tied.  The 
suture  is  intntdueed  at  right  angles  to  the  direetion  of  the 
wound,  passing  through  eorresponding  points  on  o})posite 
sides.  The  needles  are  })assed  either  with  the  free  hand  or 
are  grasped  and  direeted  by  forceps-like  instruments, 
needle-holders    (Fig.    31).     In    so-called    pedunculated 


.»«*<!5B^!»^^^:WW?>^^W■<•<.^^■^<t•'^■:?»««S"»■'f•,'^■f!«:V  '•^ 


Fio.  ^f). — Simple  continuous  suture. 


Fig.  27. — Continuous  glover's  suture. 


Fig.  28. — Continuous  mattress-suture. 


needles  the  needle  and  its  holder  form  a  continuous 
instrument.^ 

Silk,  catgut  (absorbable),  and  metallic  wire  (silver, 
lead)  are  used  as  suture-material. 

If  the  Avound  be  but  superficial,  approximation  of  the 
margins  of  the  skin  with  sutures  will  be  sufficient,  the 
needle  being  introduced  in  general  at  a  greater  or  lesser 

*  In  the  United  States  many  surgeons  use  Hagedorn  needles.  For 
intestinal  work  small,  sharp,  round  .ccwing-needles  are  employed,  pref- 
erably calyx-eyed,  which  are  easily  threaded. — Ed. 


46 


OPERATIVE  SURGERY. 


distance  from  the  margin  of  the  wound,  in  accordance 
with  its  depth. 

In  order  to  avoid  the  formation  of  cavities  in  the  closure 
of  sinuous  wounds  it  is  wise  either  to  unite  the  tissues  in 


Fig.  29. — Varieties  of  surgical  needles, 

the  depth  of  the  wound  (buried  suture),  or  to  approximate 
extensive  surfaces  of  the  wound. 

If  the  wound  be  a  complicated  one,  muscles,  tendons, 
and  nerves  being  injured,  these  structures  must  be  sever- 


Fig.  30. — Gauze-pad  suture. 


ally  isolated  and  united  before  closure  of  the  wound  is 
proceeded  with. 


j{i:usiuy  OF  the  tissues. 


liEUMn.y  or  Tiir:  tissues'.  49 

Tn  tlu'  closure  ol  ciilancous  woiiiids  tlic  .siiiij)/c  knotted 
silk  (intcmijitnJ)  sufnir  is  siilliciciit  { I'i^.  2~)).  \W  tlio 
introduction  of  deep  and  superliciid  sutures  the  endeiivor 
is  made  to  secure  as  perfect  ai)j)roxiuiatiou  as  possible  of 
the  surfaces  of  the  wound  and  niarij;ins  of  the  skin.  In- 
version of  the  latter  is  to  he  avoided  hy  accurate  approxi- 
mation of  tlie  margins  of  the  wound. 

The  contimtous  suturCy  a  single  thread  being  employed 
without  interruption,  is  also  available  in  the  union  of  cu- 
taneous wounds.  It  is  ap[)lied  in  various  ways,  as  in  the 
single  running  suture  (Fig.  26),  as  the  glover's  suture 
(each  loop  being  tied  separately,  but  not  cut  apart — Fig. 
27),  and  as  the  mattress-suture  (running  back  and  forth 
through  both  lips  of  the  wound — Fig.  28).  The  mode  of 
introduction  is  illustrated  in  the  accompanying  figures. 

When  extensive  areas  of  wound-surface  are  to  be 
brought  in  approximation  deep  sutures  are  employed, 
both  extremities  of  the  thread  being  armed  with  either 
lead  plates  (Lister)  or  small  pads  of  gauze  (Wolfler)  (Fig. 
30).  As  the  suture,  thus  apj)lied,  may  be  drawn  firmly 
together  and  be  securely  fixed,  it  is  possible  to  bring  the 
maroins  of  the  wound  in  contact  throughout  a  considerable 
extent.  Intercalated  knotted  sutures  will  insure  exact 
approximation  of  the  margins  of  the  wound.  In  using 
Lister's  lead-plate  suture  wire  is  employed  as  the  suture- 
material,  the  fixation  being  effected  by  means  of  small 
perforated  lead  buttons,  which  are  drawn  over  the  wire, 
then  pressed  flat  with  a  pair  of  forceps  and  thus  securely 
fixed. 

Divided  muscles  are  united  with  knotted  catgut  or  silk 
sutures  in  such  a  manner  that  the  cut  surfaces  are  brought 
together  in  accurate  apposition.  Kangaroo-tendon  is  often 
used  as  material  for  buried  sutures. 

In  uniting  divided  tendons  also  the  cut  ends  should  so 
far  as  possil)le  be  brought  in  apposition.  In  the  union  of 
flat,  band-like  tendons — for  instance,  the  extensors  on  the 
dorsum  of  the  hand  and  on  the  extensor  asjiect  of  the 
fingers — the  divided  ends  may  be  overlapped  and  thus 

4 


50  OPERATIVE  SURGERY. 

sutured.     Hiiter  recommended  in  all  instances  the  em- 
ployment of  this  so-called  paratendinous  suture  (Fig.  32). 


Fig.  32. — Paratendinous  suture. 

Strong,  thick  tendons,  such  as  the  flexors  of  the  fingers, 
the  tibialis  anticus  and  posticus,  the  peronei,  etc.,  may, 
when  divided,  be  united  by  simple  knotted  fine  silk  sutures 
applied  in  a  longitudinal  direction.  To  prevent  cutting 
through  of  the  sutures  these  may  be  advantageously 
passed  at  right  angles  through  the  divided  extremities 
(Fig.  33). 


Fig.  33. — Transfixion  of  divided  tendon  by  suture. 

The  application  of  supporting  loops  of  thread,  which 
are  subsequently  tied  together,  is  also  a  useful  procedure 
(Fig.  34). 


Fig.  34. — Ends  of  divided  tendon  held  by  supporting  loops. 

Before  suture  of  a  tendon  is  undertaken  preliminary 
operative  procedures,  such  as  division  of  the  skin  and  of 
the  sheath  of  the  tendon,  are  sometimes  necessary  in 
order  to  secure  the  central  extremity  of  tlie  tendon.  The 
same  end  may  often  be  attained  by  centrifugal  bandaging 
of  the  part,  or  with  the  aid  of  a  sharp  tenaculum.  After 
the  tendon  has  been  united  by  suture  it  is  important  so  to 


RE  us  ION  OF  THE   TISSUES.  51 

place  the  extremity  operated  iii)on  in  its  dressing  that  the 
tendon  is  MKiintaincd  in  a  j)osition  of  ii:r('atest  possible  re- 
hixation  nntil  lirni  union  has  taken  place. 

If  by  reason  of  seiianition  of  the  extremities  of  a  divided  tendon  ap- 
proximation cannot  be  eUetted  in  tlie  nsual  manner,  tlie  continuity  of 
tl>e  tend(tn  may  be  established  by  means  of  an  auxiliary  operation,  teno- 
plastij.  From  the  side  of  one  of  the  extremities  of  the  divided  tendon  a 
small  i)ortion  is  so  freed  that  it  ean  be  turned  over  toward  the  other  ex- 
tremity, with  which  it  is  united  by  suture  (Fig.  35).' 

Nerve-sutarey  as  first  practised  by  Robert  and  Nelaton, 
may  be  enipk)yed  in  cases  of  recent  injnries  attended 
with  division  of  nerves,  as  well  as  a  secondary  procedure 
after  isolation  and  freshening  of  the  divided  extremities. 
The  object  of  nerve-suture  is  the  approximation  of  the 


Fig.  35. — Hiiter's  tenoplasty. 

transverse  edges  of  the  divided  nerve-strand.  To  this 
end  fine  threads  are  passed  either  directly  through  the 
substance  of  the  nerve,  and  the  transverse  surfaces  of  the 
divided  extremities  are  brought  in  apposition,  or  the  ex- 
tremities are  so  united  that  they  overlap  one  another  upon 
their  lateral  surfaces  (paraneural  siitare). 

The  extremities  of  the  divided  nerve  may  be  so  united 
that  the  sutures  are  not  passed  through  the  substance  of 
the  nerve,  but  through  the  surroundinir  connective  tissue. 
In  this  way  the  extremities  are  brought  indirectly  in  ap- 
proximation (perineural  suture). 

Neuroplastj/,  based  upon  the  same  principle  as  the 
tenoplasty  of  Hiiter,  may  also  be  employed  successfully 
in  the  union  of  divided  nerves. 

^  Instead  of  silk,  we  can  employ  kangaroo- tendon  or  chromic  gi't. — 
Ed. 


52 


OPERATIVE  SURGERY. 


The  position  and  fixation  of  the  extremity  operated 
upon  should  prevent  all  disturbance  of  the  nerve  after  the 
operation. 

The  union  of  hones  is  effected  by  suture  in  a  manner 
analogous  to  that  in  which  the  soft  tissues  are  united 
(Fig.  36),  except  that  wire  is  employed  with  especial  ad- 
vantage as  suture-material.     The  channels  for  the  pas- 


FiG.  36.— Suture  of  the  patella  with  wire. 

sage  of  the  sutures  must  be  made  by  means  of  a  drill 
or  an  awl.  The  Avires  are  fastened  by  twisting  their  ex- 
tremities together.  Braces  or  clamps  also  may  be  em- 
ployed in  the  same  way  as  they  are  used  in  securing 
boards  in  scaffolding  (Gussenbauer's  clamp,  Fig.  37). 

Severed  bones  may  further  be  united  by  means  of  nails 
or  ivory  pegs  (Fig.  38).     Nails  may  also  be  driven  into 


REUMos  or  Till-:  rissvKs. 


63 


the  bone  tlirouuli  the  ovcrlyiiii^  soft  tissues  in  m-ilci-  U) 
maintain  the  iVaL»;nients  in  :i|)|)<>sili<ui  ( perentaneous  nail- 
inir  of  hones). 

Metallic  sutures,  ])eo:s,  and  nails  are  only  to  he  removed 
after  the  lai)se  of  weeks,  when  firm  union  of  the  divided 
bone  has  taken  plac*'. 

Special  Forms  of  Suture. — Suture  of  the  Bowel. — 
It  may  he  necessary  to  unite  either  a  iK'netratiufr  or  a 
non-j)enetratin<i:  wound  of  the  intestine,  or  tlie  completely 
divided  howel  throuii'liout  its  whole  circumference.  The 
suture  should  in  general  he  so  applied  that  the  resistant 
layers  of  the  intestinal  wall,  such  as  the  muscularis,  are 
brought  in  accurate  apposition  l)y  means  of  closely  applied 


n 


Fig.  37.- -Bone-brace. 


a         b 
Fig.  38.— o,  metallic  nail ; 
h,  ivory  peg. 


knotted  sutures.  Over  these  broad  folds  of  sero.sa  should 
be  approximated  by  suture,  to  facilitate  rapid  primary 
union. 

In  the  introduction  of  intestinal  sutures  the  affected 
portion  of  bowel  is  brought  out  through  the  abdominal 
wound  and  suitably  protected  against  cold  and  infection. 
The  escape  of  intestinal  contents  .should  be  prevented. 
To  this  end  the  intestine  is  grasped,  centrad  and  peripli- 
erad  of  the  wound  to  be  united,  with  suitable  clamps 
(Gussenbauer's,  Rydygier's,  Hahn's  intestinal  clamps), 
with  the  fingers,  or  with  bands  of  sterilized  gauze. 

Linear  Avounds  of  the  intestine  or  the  stomach,  as  well 
as  of  the  gall-bladder,  are  united  by  two  rows  of  closely 


54  OPERATIVE  SURGERY. 

Plate  I.— Suture  of  the  Bowel. 

Fig.  1. — Intestinal  sutures  introduced  from  the  serous  surface-  a,  in- 
volving all  layers  with  the  exception  of  the  mucosa  ;  b,  Lembert's  sero- 
serous  suture. 

Fig.  2. — Circular  intestinal  suture,  applied  from  the  lumen  of  the 
bowel  and  including   all  layers. 


placed  knotted  sutures  of  silk.  In  the  suture  of  wounds 
of  the  intraperitoneal  portion  of  the  urinary  bladder 
catgut  is  to  be  preferred.  The  first  row  of  sutures  in- 
cludes all  of  the  divided  layers.  It  is  unimportant 
whether  the  mucous  membrane  be  included  or  not,  while 
it  is  highly  important  that  a  thick  layer  of  the  muscularis 
is  included.  The  sutures  are  applied  closely  together  and 
from  either  the  serous  surface  or  the  lumen  of  the  bowel. 
In  the  first  instance  the  sutures  are  to  be  tied  externally, 
in  the  latter  internally.  When  the  suture  has  been  thus 
applied  throughout  the  whole  extent  of  the  wound  and 
closure  has  been  effected,  a  seroserous  suture  (Lembert) 
is  finally  introduced.  Surfaces  of  serous  membrane  from 
4  to  5  mm.  wdde  are  brought  in  apposition  by  introducing 
the  needle  a  short  distance  from  the  margin  of  the  wound 
and  bringing  it  out  close  to  the  margin,  and  repeating  the 
process  in  reversed  order  upon  the  other  side.  When  the 
ends  of  the  suture  are  tied  the  serous  layer  on  either  side 
is  raised  in  folds,  so  that  two  broad  surflices  of  perito- 
neum are  brought  in  approximation.  In  order  to  give 
greater  stability  to  the  seroserous  suture  the  subserous 
tissues  and  even  a  portion  of  the  muscularis  are  taken  up 
with  the  serous  layer.  The  folds  thus  formed  are  thicker, 
while  a  considerable  extent  of  surface  is  brought  in  appo- 
siticm  (Plate  1,  Fig.  1). 

Both  rows  of  intestinal  suture  may  be  applied  in  the 
form  of  knotted  sutures,  or  as  a  continuous  suture. 

If  a  divided  portion  of  bowel  is  to  be  united  through- 
out its  circumference,  similar  principles  may  be  followed. 
Two  rows  of  closely  applied  sutures  will  suffice.  The 
first  includes  all  of  the  layers  of  the  bowel,  and  is   in- 


Tab. 


Fui  1 


m 


^-^m^ 


FigZ. 


f 


I.ilh .  Ansi  K  Reichhold.  Mimchen 


REUNIOy   OF  THE  TISSUES.  55 

t('n'.](Ml  to  fix  the  cut  surfaces  in  a|)|)()siti()n  ;  the  second 
brings  tlic  serous  surfaces  to<:;ether.  Tlic  o])erator  sliould 
see  that  correspondin*^  portions  of  the  circumference  are 
hroujj^iit  accurately  in  contact  w  ith  one  another.  To  this 
end  a  suture  is  applied  at  the  nieseiiterict  attaclnnent  of 
the  bowel  and  also  one  at  a  correspondini^  point  on  the 
opposite  side  of  the  periphery,  l)oth  involving  all  of  the 
layers  of  bowel.  In  this  way  the  entire  circumference  is 
divided  into  two  ecpial  p;irts.  The  margins  of  that  ])or- 
tion  most  removed  from  the  operator  are  first  united  either 
by  closely  applied  knotted  sutures,  or  a  continuous  suture, 
ami  it  is  advisable  under  these  circumstances  to  ap])ly 
and  tie  the  sutures  from  the  lumen  of  the  bowel.  This 
suture  should  include  all  of  the  layers  of  the  bowel,  and 
care  should  be  taken  that  thick  layers  of  the  nmscularis 
are  brought  into  intimate  a])position.  The  margins  of 
the  wound  closest  to  the  oj)erator  are  first  united  by 
sutures  passed  from  and  tied  upon  the  serous  surface. 
AVhen  this  suture,  including  all  the  layers  of  the  bowel, 
has  been  ap])lied  to  the  entire  ])eriphery  of  the  bowel 
closure  will  have  been  substantially  effected.  In  order 
to  secure  primary  union  of  the  intestinal  wound  witiiin  a 
short  time  a  second  ro\y  of  seroserous  (Leml)ert)  sutures 
is  applied  over  tiie  first.  Under  these  circumstances, 
also,  it  is  advisable  to  include  with  the  serous  layer  a 
])(>rtion  of  the  muscular  layer,  as  in  this  way  the  serous 
folds  are  made  firmer  and  can  be  brought  in  closer 
approximation. 

Suture  of  the  bI((fJ(Jer,  when  the  injury  involves  the 
intraperitoneal  ])ortion  of  this  viscus,  is  effected  upon 
principles  similar  to  those  that  have  been  just  laid  down, 
except  that  in  this  event  it  is  advisable,  in  order  to  avoid 
incrustations,  to  use  catgut  instead  of  silk  as  the  suture- 
material.  One  row  of  sutures  will  accurately  approxi- 
mate the  muscular  layer  of  the  bladd(M',  which  is  often 
from  one-half  to  one  centimeter  thick.  It  is  customary 
to  exclude  the  mucous  membrane  from  the  suture.  A 
second  ro\y  of  Lembert's  sutures  unites  the  serosa.     In 


56  OPERATIVE  SURGERY. 

the  closure  of  wounds  of  the  bladder,  as  in  closure  of 
those  of  the  intestine,  the  continuous  suture  or  closely 
applied  knotted  sutures  may  be  employed. 

Wounds  of  the  extraperitoneal  portion  of  the  bladder 
are  to  be  so  united  that  the  thick  layer  of  muscular  tissue 
is  brought  in  firm  apposition  by  means  of  catgut  sutures, 
with  exclusion  of  the  mucosa. 

The  various  methods  of  suture  for  closure  of  wounds 
of  the  bladder  have  been  largely  supplanted  by  the  simple 
method  just  described. 

Wounds  of  the  gall-bladder  may  be  closed  by  suture  in 
a  manner  analogous  to  those  of  the  bowel. 


LIGATIOX  OF   VESSELS  IS  coyTiyUITY.  57 

I.  OPERATIONS  ON  THE  EXTREMITIES. 

I.   Ligation  of  \  esse  Is  in  Continuity. 

An  injured  and  bleeding  vessel  may  be  seized  directly 
within  a  wound  and  the  hemorrhage  controlled  bv  liga- 
tion. Another  mode  of  pnx}e<:lure  consists  in  exjxisure 
of  the  central  extremity  of  the  divided  vessel  for  the 
piu-pose  of  its  ligation.  This  variety  of  ligation  of 
vessels  in  continuity   will  n«»\v  l»e  considered. 

Indications. — {!)  Injuries. — {a)  ^^iab-woundsj  gun- 
shof-icoundsy  contused  icoundsy  and  lacerated  wounds  of 
the  large  arteries.  If  possible,  ligation  is  to  be  under- 
taken at  the  site  of  injury.  This  is  dit!icult  in  lacerated 
tissues  suffused  with  Ijhxxl,  when  the  wound  is  uutavorablv 
situated,  or  when  the  artery  is  injured  directly  at  its  origin 
from  a  main  branch. 

(b)  Subcutaneous  laceration  of  large  vessels;  also  when 
ligation  at  the  site  of  the  lesion  is  impossible. 

(2)  Hemorrhages  fr(.>ni  suppurating  wounds  through 
erosion  of  laro:e  vessels :  further  arterial  hemorrhagre 
from  gangrenous  tissues   or  dismteo-rating  new-growths. 

(3)  In  order  to  render  an  operation  bloodless  the  main 
arterial  branch  of  the  operative  area  may  be  previously 
ligated — e.  g.^  the  lingual  artery  preceding  extirpation  of 
the  tongue,  the  femoral  artery  preceding  enucleation  of 
the  hij>-joint,  and  preceding  extirpation  of  cavernous 
tumors. 

(4)  In  order  to  induce  retrogression  of  morbidly  altered 
organs  or  neoplasms  the  blood-supply  is  cut  off  by  ligation 
of  the  main  artery — e.  g.y  of  the  thyroid  artery  in  the 
presence  of  goiter,  of  the  spermatic  artery  in  the  presence 
of  tumors  of  the  testicle,  of  the  internal  iliac  artery-  in 
the  presence  of  hypertrophy  of  the  prostate,  etc.  In  the 
same  category  belongs  the  treatment  of  elephantiasis  of 
the  les:  bv  ligation  of  the  external  iliac  or  the  femoral 


58  OPERATIVE  SURGERY. 

artery,  with  -which  some  surgeons  have  secured  good 
results.^ 

(5)  Aneurysms. — According  to  the  method  of  Hunter, 
the  afferent  artery  is  ligated  in  the  treatment  of  aneurysm, 
but  on  account  of  the  supply  of  bh)od  to  the  aneurysmal 
sac  throuoh  the  collateral  circulation  this  method  is  not 
so  reliable  as  that  of  Antyllus. 

In  cases  of  trigeminal  neuralgia  resisting  other  operative 
measures,  ligation  of  the  carotid  artery  has  been  repeatedly 
practised  (Patruban). 

The  treatment  of  epilepsy  by  ligation  of  the  vertebral 
artery  has  also  been  proposed. 

Method  of  I^igation. — At  definitely  determined 
points  upon  the  surface  of  the  body  the  skin  is  divided 
and  with  careful  protection  of  important  structures  the 
sheath  of  the  vessel  is  exposed.  This  is  then  opened,  and 
the  artery,  separated  from  the  accompanying  veins  for  a 
small  portion  of  its  extent,  is  raised  from  its  bed  for  the 
purpose  of  ligation.  Two  ligatures  are  now  applied,  and 
the  artery  is  divided  transversely  between  them  with  a 
sincrle  cut  of  the  scissors.  The  wound  in  the  skin  is 
closed  by  suture. 

The  cutaneous  incisioni<  are  made  in  selected  situations 
in  a  definite  direction  so  as  to  render  possible  access  to 
the  artery  by  the  sliortest  route.  Usually  the  incision  in 
the  skin  corresponds  witli  the  course  of  the  artery.  Thus,  in 
the  extremities  this  incision,  with  a  few  minor  exceptions, 
coincides  with  the  longitudinal  direction  of  the  vessel. 

In  order  that  the  incision  in  the  skin  may  be  placed  in 
the  proper  situation,  it  is  necessary  to  make  careful  scrutiny 
of  the  surface  of  tlie  body.  To  facilitate  this,  prominent, 
readily  palpable  points  of  the  skeleton,  as  well  as  nuiscular 
prominences,  and  the  intervening  depressions,  are  selected 
as  landmarks. 

1  In  some  regions  extirpation  of  a  vessel  is  better  tlian  ligation,  if  we 
wish  to  arrest  the  growth  of  a  tumor.  Davvbarn  has  recently  pointed 
out  that  ligation  of  the  external  carotid  is  of  slight  value  in  sarcoma  of 
the  tonsil,  as  the  anastomotic  circulation  is  so  quickly  established,  but 
extirpation  of  this  vessel  causes  great  shrinking  of  the  growth. — Ed. 


LIGATION  OF   VESSELS  IX  CONTISUirV.  .',9 

The  k'litrth  of  tin*  cutaiK'oiis  incision  will  he  regulated 
by  the  de})th  to  w  liieh  aecess  is  desired  :  the  deeper  the 
\vonn(l  tlic  hirtrcr  must  he  the  openiuir  in  tlic  skin.  Tlie 
incision  ior  exposure  of  the  internal  iliac  artery  will  meas- 
ure from  15  to  20  cm.  (6  to  8  in.),  while  that  for  the  ra- 
dial artery  at  the  wrist-joint  need  not  he  more  than  1  (jr 
1.0  em.  (^  or  ^  in.).^ 

A\'hen  the  skin  and  the  suhcutaneous  connective  tissue 
have  heen  penetrated  (the  base  of  the  wound  is  no  longer 
moved  with  movements  of  the  margins  of  the  skin),  the 
sheath  of  the  vessel  is  carefully  approached  by  dissection 
either  w  ith  the  free  hand,  between  two  pairs  of  forceps, 
or  with  the  aid  of  the  grooved  director.  Muscles,  nerves, 
and  veins  that  obstruct  the  way  are  displaced  with  1)1  unt 
hooks.  If  a  vessel  prevents  access  to  the  arter}',  it  may 
be  ligated  in  two  places  and  divided  between. 

The  sheath  of  the  vessel  is  detached  from  the  artery  for 
a  short  distance  by  blunt  dissection  with  anatomic  forceps, 
or  it  is  divided  upon  the  grooved  director,  in  accordance 
with  the  character  of  the  tissues.  After  the  sheath  has 
been  opened,  either  a  single  vessel  will  be  exposed  <jr  both 
artery  and  vein  will  come  into  view.  The  most  reliable 
guides  are  furnished  by  the  topographic-anatomic  relations. 
The  artery  must  be  recognized  as  such  from  its  situation, 
as  all  other  means  of  identification  may  under  circum- 
stances fail.  The  color  of  the  vessel  is  as  little  distinctive 
as  is  its  thickness,  as  the  walls  of  both  arteries  and  veins 
possess  the  same  color  in  the  dead  subject  in  consequence 
of  imbibition,  while  the  thickness  of  the  wall  of  the 
vessel  is  subject  to  wide  individual  variations.  As  a 
rule,  however,  the  walls  of  the  arteries  are  thicker  than 
those  of  the  veins,  although  not  rarely  in  enfeebled  indi- 
viduals, and  particularly  in  females,  the  arteries  are  small 
and  thin-walled.  It  might  be  supposed  that  during  life 
pulsation  of  the  vessel  would  })e  an  infallible  means  of 
recognizing  the   arteries ;    but  this  is  not  always  so,  as 

1  Operation  through  a  very  small  incision  is  often  possible,  but  it  is  a 
needless  effort  and  is  unsafe  for  a  beginner. — Ed. 


60 


OPERATIVE  SURGERY. 


arteries  at  times  exhibit  no  pulsation  after  free  loss  of 
blood,  while  on  the  other  hand  veins  may  apparently  pul- 
sate through  transmission  of  movement  in  the  arteries. 
The  anatomical  relations  therefore  are  the  only  reliable 
guides  for  distinguisliing  between  artery  and  vein. 

When  the  sheath  of  the  vessel  has  been  opened  and  the 
artery  brought  into  view,  this  must  be  isolated  with  two 


Fig.  39. — Artery  divided  between  two  ligatures. 

pairs  of  forceps  for  a  distance  of  1  or  l-l-  cm.  (l-i  in.) 
and  raised  from  its  bed  for  the  application  of  the  ligature. 
To  this  end  one  lip  of  the  opened  sheath  is  grasped  with 
a  pair  of  forceps  held  in  the  left  hand  and  traction  made, 
while  with  the  blades  of  the  other  pair  of  forceps  held 
in  the  left  hand  the  loose  tissue  surrounding  the  artery  is 


LIGATins  OF   VESSELS  IN  COyTINUlTY.  Gl 

detaclu'd  in  its  longitudinal  direction.  From  time  to  time 
the  fixing  and  the  disstrting  hand  arc  alternated,  care 
being  taken  to  avoid  inclusion  of  the  artery,  of  a  vein,  or 
of  a  nerve  l)et\veen  the  blades  of  the  forceps.  From  the 
side  of  the  artery  next  which  lies  the  vein  [or  rather  the 
most  dangerous  neighbor,  for  in  some  situations  the  nerve 
must  be  avoided  ratlier  than  the  vein. — Fl>.],  the  ligating 
instrument,  armed  witli  a  ligature,  is  passed  beneath  the 
artery,  the  ligature  wound  about  the  vessel  and  tied.  A 
second  ligature  is  applied  in  similar  manner  at  about  a 
distance  of  1  cm.  (^  in.^  from  the  first,  and,  between  the 
two,  the  artery,  raised  from  its  bed,  is  cut  squarely  with 
a  single  stroke  of  the  scissors.  The  divided  ends  of  the 
vessel  retract  somewhat  in  either  direction  (Fig.  39). 
The  application  of  two  ligatures  and  cutting  between 
possess  some  advantages,  but  are  not  always  necessary. 

The  retraction  and  the  relaxation  of  the  extremities  of 
the  divided  vessel  afford  more  favorable  conditions  for 
thrombus-formation,  through  narrowing  of  the  lumen, 
than  simple  occlusion  of  the  lumen  of  the  vessel.  Beside, 
by  division  of  the  vessel  Ijetween  the  ligatures  a  view 
is  obtained  of  the  posterior  wall  of  the  artery,  and  in  this 
way  ligature  of  the  artery  just  in  advance  or  just  beyond 
the  orio^in  of  a  lateral  branch  can  be  avoided.  Either 
contingency  is  equally  unfavorable  to  thrombus-forma- 
tion. The  small  wound  made  is  closed  with  knotted 
sutures. 

The  knot  of  the  ligature  is  tied  as  follows  :  after  the 
ligature  has  been  made  to  surround  the  arter}'  the  free 
end  on  either  side  is  grasped  with  the  fingers  of  the  cor- 
responding hand.  Before  the  knot  is  tied  the  ends  are  so 
crossed  that  the  right  passes  behind  the  left  and  is  re- 
ceived into  the  left  hand,  while  the  left  passes  in  front  of 
the  right  and  is  received  into  the  right  hand.  When  the 
extremities  have  been  thus  crossed  a  sinq^le  knot  is  tied. 
Before  the  second  knot  is  placed  upon  the  first  the  free 
extremities  must  again  be  changed  and  in  such  a  manner 
that  that  upon  the  left  is  passed  in  front  of  that  upon  the 


62 


OPERATIVE  SURGERY. 


right.  Tlie  sailor^s  knot  (Fig.  40)  thus  fijrmed  is  more 
secure  than  the  ordinary  granny^ s  knot  (Fig.  41). 

If  in  the  first  part  of  the  knot  the  extremities  are 
twisted  twice,  instead  of  once,  there  results  the  so-called 
surgical  knot  (Fig.  42). 

The  sailor's  knot  is  employed  not  only  in  the  applica- 
tion of  ligatures,  but  whenever  it  is  desired  to  tie  a  secure 
knot. 

lyigations  in  the  Upper  Extremity. — The  arter\^ 
supplyino'    the  arm,  the  forearm,  and  the  hand    may  be 


Fig.  40. — Sailor's  knot  [reef-knot]. 


Fig.  41. — Granny's  knot. 


Fig.  42. — Surgical  knot. 


exposed  for  purposes  of  ligati<m  in  the  axilla,  upon  the 
upper  arm,  at  the  flexure  of  the  elbow,  and  upon  the 
forearm. 

The  axillary  artery  is  the  continuation  of  the  subclavian 
from  the  lower  border  of  the  fourth  ril)  to  the  surgical 
neck  of  the  humerus.  When  the  arm  is  abducted  it  lies 
in  intimate  relation  with  the  bone ;  below  the  pectoralis 
minor  the  vessel  lies  in  contact  with  the  coraco-brachialis. 
Of  the  brachial  plexus  only  the  median  nerve  is  situated 


LIGATION  OF   VKSSIJLS  IX  COyTIXriTY. 


03 


in  front  (»f  tlic  artery,  tlic  axillary  vein  lyin<r  toward  tlio 
MiitMlc  line  and  at  a  more  supcrlicial  level. 

Ligation  of  the  Axillary  Artery. — The  body  occupies 
the  dorsal  deeuhitiis,  with  the  arm  ahdueted  and  held  at  a 
riu'ht  anule  to  tlie  trunk  in  such  a  manner  that  tin;  ex- 
tended iorearm  assumes  a  position  midway  between  pro- 
nation and  supination.  The  operator  stands  between  the 
thorax  and  the  abducted  arm,  the  assistant  to  his  left.  The 
axillary  cavity  is  exposed  to  view,  with  its  boundaries,  the 


Fig.  43. — Axillary  cavity :  incisions  for  exposure  of  the  axillary  artery 
and  the  brachial  arterj". 

anterior  (border  of  the  pectoralis  major)  and  posterior 
axillary  folds  (border  of  the  latissimus  dorsi  and  teres 
major),  between  which  when  the  arm  is  abducted  the  skin 
occupies  the  concavity  of  the  axilla.  In  the  latter  the 
prominence  of  the  head  of  the  humerus  is  both  visible  and 
palpable.  Upon  the  arm,  whose  inner  aspect  is  directed 
toward  the  operator,  is  the  internal  bicipital  sulcus,  run- 
ning parallel  with  the  arm  between  the  l^ellies  of  the 
biceps  and  the  triceps.     This  groove  forms  the  main  bed 


64  OPERATIVE  SURGERY. 

Plate  2.— Exposure  of  the  Axillary  Artery  and  the  Brachial 

Artery. 

Mcb,  coracobrachialis ;  /,  inner  portion  of  the  fascia  of  the  upper  arm  ; 
M,  median  nerve;  Ci,  lesser  internal  cutaneous  nerve;  Ca,  greater  in- 
ternal cutaneous  nerve;  Ax,  axillary  artery;  B,  biceps;  Fb,  brachial 
fascia.     A,  brachial  artery.     J '6,  brachial  vein. 

of  the  vessels  and  nerves  of  the  arm.  It  does  not  extend 
quite  to  the  anterior  axillary  fold,  as  the  belly  of  the 
biceps  diminishes  in  size  at  this  point  before  passing  over 
into  the  tendon.  The  border  of  the  pectoralis  major  and 
the  upper  extremity  of  the  biceps  form  here  two  sides  of  a 
triangle  whose  base  is  constituted  by  the  coracobrachialis 
(Fig.>3)._ 

This  triangle,  formed  by  the  elevations  of  three  mus- 
cles, is  the  situation  in  which  the  artery  is  to  be  exposed. 

It  would  be  a  mistake  to  look  for  the  vessel  in  the  axil- 
lary cavity,  which  forms  a  space  filled  with  flit,  connective 
tissue,  and  lymphatic  glands  next  to  the  lateral  wall  of 
the  chest.  The  artery,  which  lies  close  to  the  humerus, 
is  therefore  to  be  looked  for  in  relation  with  this  bone  at 
the  apex  of  the  axillary  cavity. 

The  incision  is  made  along  the  line  of  the  coracobrach- 
ialis muscle  in  the  continuation  of  the  internal  bicipital 
sulcus  (Fig.  43).  After  the  subcutaneous  connective 
tissue  has  been  passed  the  thin  fascia  of  the  arm  will  be 
exposed,  through  which  the  fibers  of  the  coracobrachial 
muscle  will  be  visible.  The  fascia  is  divided  upon  the 
grooved  director  and  the  lower  (inner)  lip  of  the  wound 
in  skin  and  fascia  retracted  with  tenacula.  There  now 
comes  into  view  the  median  nerve  embedded  in  loose 
cellular  tissue,  and  this  is  drawn  out  of  the  way  with  a 
simple  blunt  hook.  The  artery  is  now  exposed  and  can 
be  readily  isolated  and  ligated  (Plate  2).  Care  must  be 
taken  that  the  ner^^e  alone  is  grasped  and  drawn  out  of 
the  way,  as  otherwise  the  artery,  which  lies  directly  behind 
it,  may  also  be  displaced  and  removed  from  the  field  of 
vie\v. 


Tab.     2. 


LUh.Anst  F.  Reichhold,  Mimchen. 


LIGATION  OF   VESSELS  IN  CONTINUITY.  65 

After  division  oi'  tlic  i'ascia  of  the  coracobraclnal  imis- 
c'l(^  the  orcatcr  internal  cntancuns  nerve  sometimes  pre- 
sents itself.  'I'liis  small  nerve  can  scarcely  be  eonfoundeil 
with  the  median  nerve,  which  comes  into  view  after 
fnrther  retraction  of  the  lower  (inner)  margin  of  the 
wonnd. 

The  artery  is  accompanied  by  one  or  several,  sometimes 
by  a  whole  ])lexus  of  veins. 

Ligation  of  the  Bracliial  Artery. — The  continuation  of 
the  axillary  artery  from  the  surgical  neck  of  the  humerus 
to  its  point  of  division  at  the  flexure  of  the  elbow  is 
known  as  the  bracJikd  (irtcry.  The  vessel  lies  in  the  in- 
ternal bicipital  sulcus,  and  it  is  often  accompanied  by  a 
network  of  veins.  The  median  nerve  lies  over  the  upper 
half  of  the  artery,  which  it  conceals,  while  in  their  fur- 
ther course  the  nerve  lies  upon  the  ulnar  side  of  the  ves- 
sel. The  basilic  vein,  which  likewise  lies  in  the  internal 
bicipital  sulcus,  is  separated  from  the  group  of  large 
vessels  and  ni^rves  by  the  fascia.  The  sheath  of  the 
vessel  consists  of  loose  cellular  tissue. 

The  patient  occupies  the  same  position  as  in  ligation  of 
the  axillary  artery.  The  incision  is  made  at  about  the 
middle  of  the  arm,  slightly  over  (external  to)  and  parallel 
with  the  internal  bicipital  sulcus  (Fig.  43).  Skin  and 
subcutaneous  connective  tissue  are  divided  and  the  fascia 
of  the  biceps  muscle  is  opened  in  the  same  direction  and 
throughout  the  same  extent.  The  fibers  of  this  muscle 
must  be  clearly  exposed  to  view.  The  lower  (inner)  lip 
of  the  wound  in  the  fascia  is  drawn  downward  (inward) 
with  a  tenaculum  and  the  median  nerve  thus  exposed. 
The  nerve  is  lifted  from  its  bed  and  drawn  aside  with  a 
blunt  hook,  when  tlie  brachial  artery  is  exposed  accom- 
panied by  veins.  The  artery  is  isolated  by  means  of  two 
pairs  of  forceps  and  is  ready  for  ligature  (Plate  2). 

The  rule  to  make  the  incision  somewhat  above  (ex- 
ternal to)  the  bicipital  sulcus  in  order  to  reach  the 
median  nerve  below  is  to  be  recommended  on  account 
of  the   difficulties    encountered   in    reaching   the   artery 

5 


66  OPERATIVE  SURGERY. 

throiigli  a  mass  of  structures,  includinu:  the  greater  in- 
ternal cutaneous  nerve,  the  median  nerve,  and  the  ])asilic 
vein,  when  the  incision  is  made  directly  over  the  vessels 
and  nerves.  If  the  incision  is  made  below  (internal  to) 
the  bicipital  sulcus,  an  inexperienced  person  may  err  by 
failing  to  recognize  the  exposed  ulnar  nerve  and  looking 
in  vain  for  the  artery  behind  it. 

The  relations  bet\\'een  the  median  nerve  and  the  brachial 
artery  are  varia])le  within  certain  limits.  In  rare  in- 
stances the  artery  lies  in  front  of  the  nerve.  In  cases 
of  high  division  of  the  radial  and  ulnar  arteries  one  of 
the  vessels  lies  in  front  of  and  the  other  behind  the  nerve. 
The  presence  behind  the  median  nerve  of  an  artery  pro- 
portionately small,  as  compared  with  the  rest  of  the  body, 
is  suggestive  of  such  high  division  of  the  brachial  artery. 

Ligation  of  the  Cubital  Artery. — The  continuation  of 
the  brachial  artery  in  the  iiexure  of  the  elbow  is  known 
as  the  cubital  artery.  The  vessel  lies  in  the  internal 
cubital  sidcus,  and,  covered  by  the  aponeurosis  of  the  bi- 
ceps muscle,  is  embedded  in  the  depression  between  the 
pronator  radii  teres  and  the  biceps.  The  artery  is  in  this 
situation  accompanied  by  two  symmetrically  placed  veins. 
The  median  nerve  does  not  occupy  the  same  intimate  re- 
lation with  the  artery  as  it  does  higher  up,  but  lies  at 
some  distance  upon  the  idnar  as})ect  of  the  artery.  Sepa- 
rated from  the  artery  l)y  the  bicipital  fascia  and  situated 
subcutaneously  is  the  cubital  plexus  of  veins  (median  ba- 
silic, median  cephalic),  which  communicate  in  the  flexure 
of  the  elbow  with  the  veins  accompanying  the  artery. 

The  simplicity  of  the  relations  existing  in  the  arm  in 
consequence  of  the  prominences  formed  by  the  biceps  and 
the  triceps  and  the  presence  of  the  internal  and  external 
bicipital  sulci,  is  replaced  at  the  flexure  of  the  elbow- 
joint  by  complexity  resulting  from  the  presence  of  the 
two  large  groups  of  forearm-muscles.  The  s])indle-shaped 
belly  of  the  biceps,  which  gradually  diminishes  in  size,  is 
separated  by  a  sulcus  upon  the  right  and  the  left  respec- 
tively from   the  muscular  prominences  of  the  extensors 


LIGATION  OF   VESISELS  IN  CONTINUITY.  67 

and  Hoxurs  »)!'  tiic  fbrcarin,  wliidi  oricrinate  in  this  situa- 


FiG.  44.— Arrangement  of  the 
muscles  in  the  upper  extremity : 
Shi,  internal  l)icipital  sulcus;  f^be, 
external  bicipital  sulcus;  Sci,  in- 
ternal cubital  sulcus;  ^V,  radial 
sulcus;  Sn,  ulnar  sulcus. 


tion.     There  results  tluis  a  Y-shaped  formation,  of  which 
the  two  limbs,  in  some  degree  the  continuations  of  the 


68  OPERATIVE  SURGERY. 

Plate  3.— Exposure  of  the  Cubital  Artery. 

L,  transverse  section  of  the  aponeurosis  of  the  biceps  muscle ;  A,  cubital 
artery  accompanied  by  veins ;  31,  median  nerve  ;   V,  cubital  veins. 

Exposure  of  the  Radial  and  Ulnar  Arteries. 

A)\  radial  artery  ;  Au,  ulnar  artery  at  the  inner  side  of  the  tendon  of  the 
internal  ulnar  muscle  {U). 


bicipital  sulci  of  the  arm,  are  designated  the  internal  and 
external  cubital  sulci.  The  inner  furrow  of  the  flexure 
of  the  elbow  is  bounded  by  the  biceps  or  the  brachialis 
internus  and  the  pronator  radii  teres,  the  outer  by  the 
biceps  and  the  supinator  longus.  The  internal  bicipital 
sulcus  is  covered  by  the  radiating  aponeurosis  of  the  biceps 
(Fig.  44). 

To  ligate  the  bicipital  artery  the  forearm  is  extended  at 
the  elbow-joint  and  held  in  a  position  of  maximum  supina- 
tion. Information  as  to  the  direction  and  situation  of  the 
internal  bicipital  sulcus  is  sought  through  palpation.  The 
incision  is  made  in  the  continuation  of  the  internal  bicipital 
sulcus  and  passes  from  within  and  above  downward  and 
outward,  corresponding  to  the  direction  of  the  internal 
cubital  sulcus  (Fig.  45).  After  division  "of  the  skin  con- 
sideration should  be  given  to  the  network  of  veins  at  the 
flexure  of  the  elbow.  When  possible  the  way  is  cleared 
bv  retraction  of  the  veins  with  blunt  hooks.  The  shining 
aponeurosis  of  the  biceps  muscle  now  appears  in  the 
wound  and  it  is  divided  upc^n  the  grooved  director  in  the 
direction  of  the  cutaneous  wound.  The  artery  lies  im- 
mediately beneath  the  aponeurosis,  accompanied  by  two 
veins,  in  a  bed  of  loose  connective  tissue.  The  median 
nerve  lies  to  the  ulnar  side  of  the  artery  (Plate  3). 

In  case  of  high  division  of  the  brachial  artery  one  or  both 
branches  may  lie  ujwn  the  bicipital  fascia.  This  possi- 
bilitv  is  to  be  thouglit  of  when  bleeding  from  the  veins  at 
the  flexure  of  the  elbow  is  to  be  undertaken,  or  when  one 
of  the  median  veins  in  this  situati(m  is  to  be  exposed  and 
opened  for  infusion  with  a  saline  solution  or  for  transfusion 
of  blood. 


/h..inst.  K HeichhflUl. UtincJ 


LIGATION  OF   VESSKLS  IN  CONTINUITY. 


69 


In  the   ]tr.icti<'e  of  phlehoio 


about  thr  niiddlt'  of  tl 


]thlehi)t()}ity  a  cloth  or  handaK*'  is  hound  circularly 
ahout  tlic  niKKlU'  oi  llu- arm  in  such  a  niauiicr  that  the  return  of  hlood 
throujih  the  veins  from  the  forearm  is  prevented  witiiout  ohliteration  of 
the  radial  pulse.  With  the  forearm  extended,  a  sharp-pointed  knife  is 
introdiu-ed  obli(|Uely  into  one  of  the  tensely  distcndrtl  median  veins 
(Fig.  4t»),  so  thai  the  hlood  spurts  from  the  wound  in  a  stream.    When  the 


Fig.  45. — Incisions  for  exposure  of  the  cubital,  radial,  and  ulnar 

arteries. 

desired  amount  of  blood  has  escaped  the  compress  is  released,  and  the 
small  wound  is  covered  with  a  dressing  and  a  bandage. 

Transfusion  uf  blood  or  venous  infusion  of  saline  solution  also  is  prac- 
tised through  the  median  basilic  vein.  Through  an  incision  analogous  to 
that  made  for  ligation  of  the  cubital  artery  the  vein,  lying  subcutaneously. 
is  exposed  for  a  distance  of  several  centimeters  and  isolated  by  blunt 


70 


OPERATIVE  SUROERY. 


dissection.  The  vessel  is  grasped  with  a  pair  of  anatomic  forceps  and 
snipped  with  the  scissors,  without  being  totally  divided.  The  vein  is 
now  closed  by  ligature  on  the  peripheral  side  of  the  incision.  Through 
the  opening  thus  made  the  cannula  is  introduced  into  the  vein  in  a  cen- 
tripetal direction  and  fixed.  To  make  the  infusion  a  sterilized  rubber 
tube  armed  with  a  funnel  is  most  advantageously  employed,  attached  to 
the  cannula.     From  a  half-liter  to  a  liter  and  a  half  of  fluid  are  per- 


FiG.  46. — Phlebotomy  at  the  flexure  of  the  elbow  :   opening  of  the 
median  basilic  vein  by  puncture  with  a  sharp-pointed  knife. 


mitted  slowly  to  flow  into  the  vein  under  a  low  degree  of  pressure.  Fox 
purposes  of  infusion  sterilized  physiologic  (0.6  per  cent.)  solution  of 
sodium  chlorid  or  defibrinated  human  blood  may  be  employed.  After 
the  infusion  has  been  completed  the  vein  is  ligated  upon  the  central  side 
of  the, opening  and  the  small  wound  is  closed  by  suture. 

Ligation    of    the     Radial    and    Ulnar    Arteries. — The 


LIGATIoy  OF   VESSELS  IN  COXTIMITY.  71 

imiseles  iipmi  tlic  palmar  aspect  of  the  ionariii  are 
(livisll)l('  into  tlii'cc  ^inuips,  'Hie  main  mass  is  inrmcd  l)v 
the  tlc'xors  of  tlic  tinii'crs,  wliicli  arise  by  a  common  head 
iVoni  tlie  inner  aspect  of  the  lower  extremity  of  the 
hnmerns.  The  forearm  is  honnded  upon  the  ulnar  side 
by  the  flexor  carpi  ulnaris,  u})ou  the  radial  side  by  the 
supinator  longus.  Between  the  tendons  of  these  muscles 
and  the  mass  of  the  flexofs  of  the  fingers  there  is  thus 
formed  in  the  lower  third  of  the  foreariu  upon  either  side 
a  longitudinal  furrow  or  depression  which  is  used  as  a 
guide  in  finding  the  radial  and  the  ulnar  artery  respec- 
tively (Fig.  45). 

The  r(((Vml  arferjf  corresponds  in  its  course  with  the 
direction  of  the  radius.  In  the  upper  third  of  the  fore- 
arm the  artery  lies  in  close  relation  with  the  supinator 
longus  muscle  and  is  deeply  situated.  In  the  lower  third 
it  lies  more  superficially  in  the  sulcus  between  the  tendons 
of  the  flexors  and  that  of  the  supinator  longus.  Just 
above  the  wrist-joint  the  artery,  with  its  accompanying 
two  veins,  lies  upon  the  lower  extremity  of  the  radius, 
covered  only  by  skin  and  the  thin  fascia. 

The  ulnar  artery,  after  it?s  origin  from  the  brachial, 
crosses  the  common  head  of  the  flexors,  among  which  it 
pursues  its  course,  until  it  reaches  the  tendon  of  the  flexor 
carpi  ulnaris,  along  the  inner  side  of  which  it  reaches  the 
wrist-joint. 

The  typical  situation  for  the  ligation  of  both  arteries  is 
just  above  the  wrist-joint.  The  forearm  is  placed  in  a 
position  of  maximum  supination,  with  the  hand  in  slight 
dorsal  flexion.  To  expose  the  radial  artery  an  incision  is 
made  just  above  the  wrist-joint  corresponding  to  the  de- 
jH'ession  between  the  tendon  of  the  su])inator  longus  and 
those  of  the  flexors  (Fig.  45).  After  division  of  the  skin, 
the  artery,  covered  by  delicate  translucent  fascia,  is  seen, 
situated  between  two  veins.  After  division  of  the  fascia 
the  artery  can  be  isolated  and  ligated  (Plate  2). 

The  ulnar  artery  is  reached  through  a  short  incision  in 
the  ulnar  sulcus  just  above  the  wrist-joint  somewhat  to 


72 


OPERATIVE  SURGERY. 


the  mdial  side  of  the  readily  palpable  tendon  of  the  flexor 
carpi  ulnaris.  Tlie  radial  margin  of  this  tendon  is  ex- 
posed and  drawn  to  one  side  with  a  tenaculum.    The  deep 


Fig.  47.— Arrangement  of  the  muscles  of  the  thigh  :  A,  ahductor  group; 

Q,  quadriceps  femoris. 

layer  of  fascia  enclosing  the  flexors  is  brought  into  view 
aiid  divided  upon  a  grooved  director.  The  artery,  accom- 
panied by  two  veins,  is  now  disclosed.  In  close  relation 
with  the*  artery  upon  its  ulnar  side  lies  the  ulnar  nerve. 


LIGATIOy  OF   VESSELS  IS  COSTISUITY. 


73 


The  radial  arton  ,  in  its  further  eourse,  is  conveniently 
accessible  upon  tht*  chasuni  of  the  hand  between  the 
tendon  of  the  tlexor  longus  jx)llieis  and  that  of  the  exten- 
sor brevis  }X)llieis,  in  the  so-called  tabatiere. 


Fig.  4S. — Coarse  of  mc  ~.ii tonus  muscle  (S). 

In  the  palm  of  the  hand  the  snperticial  palmar  arch  of 
the  ulnar  artery  can  be  exposed  after  division  of  the 
tough  palmar  aponeurosis.  The  cutaneous  incision  in  the 
palm  passes  from  the  middle  of  the  root  of  the  hand 
toward  the  base  of  the  little  finger. 


74  OPERA  TIVE  SUEGEB Y. 

Plate  4.— Exposure  of  the  Femoral  Artery. 

Below  Poupart's  ligament,  in  the  opened  sheath  of  the  vessels,  are  to  be 
seen  upon  the  median  side  the  femoral  vein,  and  upon  its  outer  side  the 
femoral  artery.  In  the  middle  of  the  thigh  the  sartorius  muscle  (S )  is 
drawn  outward,  the  deep  layer  of  the  fascia  Vjeiug  divided,  and  the  ar- 
tery is  exposed,  with  the  vein  behind  it. 

lyigations  in  the  I/Ower  Extremity. — The  mus- 
cles of  the  thigh  are  so  grouped  tliat  Ijetween  the  exten- 
sors and  flexors,  which  are  ari'anged  symmetrically  upon 
the  anterior  and  posterior  aspects  of  the  femur,  on  the 
median  side  one  group  of  muscles  passes  from  the  pelvis 
to  the  inner  aspect  of  the  femur,  .separating  the  quadriceps 
from  the  flexors.  The  depression  thus  formed  between 
the  extensors  and  the  abductors  (Fig.  47)  sei-^'es  as  a  path- 
way for  the  vessels  passing  over  the  margin  of  the  peh'is 
and  corresponds  in  its  direction  with  the  course  of  the 
vessels.  The  sartorius  muscle  bridges  over  this  gutter 
(Fig.  48)  and  constitutes  thus  an  important  landmark  in 
locating  the  vessels. 

The  femoral  artery,  the  continuation  of  the  external 
iliac,  emerges  from  the  pelvis  under  Poupart's  ligament 
at  a  point  midway  Ijetween  the  symphysis  pubis  and  the 
anterior  superior  iliac  spine.  The  femoral  vein  at  its 
entrance  into  the  pelvis  lies  to  the  median  side  of  the 
artery.  The  artery  passes  downward  and  inward,  and  in 
its  course  follows  the  depression  between  the  extensors 
and  tlie  adductors.  From  the  middle  third  of  the  thigh 
onward  the  sartorius  muscle  lies  in  front  of  the  artery, 
which  in  this  situation  is  covered  by  the  tense  fibers  of 
the  deep  layer  of  the  fascia  lata.  The  artery,  with  its 
accompanying  vein,  enters  the  popliteal  space  through  an 
opening  in  the  adductor  magnus  (Hunter's  canal),  at  the 
junction  of  the  middle  and  lower  thirds  of  the  thigh. 
The  femoral  vein  below  Poupart's  ligament  lies  to  the 
median  side  of  the  artery.  In  the  further  cour.-e  of  the 
vessels  they  cross  in  such  a  way  that  the  vein  comes  to  lie 
behind  the  arterv.    This  relation  is  attained  in  the  middle 


Tab      4. 


Lith.  Anst  /.'  Reuhhold.  iiiinchen 


LIGATION  OF   VESSELS  IN  CONTINUITY.  75 

of  tlu'  thij^li,  and  tlie  vessels  thus  pass  t1ir()iio;li  Iliintcr's 
caiuil.     Ill  ciitcrlng  the  })()j)liteal  spae(!  I'rom  the  jjosterior 
aspect  the  vein  comes  first  into  view,  while  iu  front  of  it, 
in  intimate  relation,  lies  the  artery. 
The  femoral  artery  may  he  li*j:;ate(l : 

(1)  In  the  subinguinal  depression,  directly  below  Pon- 
part's  ligament. 

(2)  In  its  conrse  behind  the  sartorins  mnscle,  at  the 
junction  of  the  middle  and  upper  thirds  of  the  thigh. 

(3)  In  Hunter's  canal. 

I.  Ligation  of  the  Femoral  Artery  below  Poupart's  Liga- 
ment.— The  incision  into  the  skin  is  made  parallel  N\'ith 
the  axis  of  the  thigh  from  Poupart's  ligament  doNvnward 
for  a  distance  of  from  5  to  8  cm.  (2-3  in.).  The  upper 
extremity  of  the  incision  corresponds  with  a  point  mid- 
way between  the  symphysis  pubis  and  the  anterior  supe- 
rior iliac  spine  (Fig.  49,  a).  After  division  of  the  skin  and 
the  fatty  connective  tissue  careful  dissection  is  made 
downward  in  a  vertical  direc^tion  until  the  sheath  of  the 
vessels  is  recognized  by  its  fibrous  structure  and  whitish 
appearance.  The  sheath  is  divided  upon  a  grooved 
director  and  the  artery  isolated  for  a  short  distance  with 
two  pairs  of  forceps  and  raised  from  its  bed.  The 
femoral  vein  can  be  brought  into  view  upon  the  median 
side  of  the  artery.  The  crural  nerve  is  some  distance  to 
the  outer  side  of  the  vessels,  covered  by  the  deep  layer 
of  the  fascia  lata. 

II.  Ligation  of  the  Femoral  Artery  at  the  Junction  of 
the  Middle  and  Upper  Thirds  of  the  Thigh. — By  inward 
rotation  of  the  thigh  the  depression  following  the  course 
of  the  sartorius  muscle,  from  above  and  without  down- 
ward and  inward,  upon  the  inner  aspect  of  the  femur, 
can  be  brought  into  view.  The  incision  in  the  skin  is 
begun  at  the  junction  of  the  middle  and  upper  thirds  of 
the  femur,  and  follows  the  line  of  this  (lej)ression  along 
the  inner  border  of  the  sartorius  muscle  (Fig.  49,  b).  After 
the  subcutaneous  connective  tissue  has  been  passed  the 
delicate  fascia  of  the  thigh  comes  into  view  and   should 


76 


OPERATIVE  SURGERY. 


Plate  5. — Exposure  of  the  Femoral  Artery  in  the  Adductor 

Canal. 

Vi,  vastus  iaternus;  S,  sarttirius.     The  fibrous  covering  of  Hunter's  canal 
(ff)  is  divided,  with  exposure  of  the  femoral  artery  and  vein. 


Fig.  49. — Cutaneous  incision  for  ligation  of  the  femoral  artery  :  n,  be- 
low Poupart's  ligament ;  b,  below  the  sartorius  muscle ;  c,  in  the  adductor 
canal. 


Tab.     5. 


\ 


J.Uh,  AfL-it  K  Rji'ichliciU.  Mn. 


LIUATIOS   OF    VESSELS  AV   CUSTIMITy.  11 

ho  divided  in  the  direction  of  the  eiitniieons  iiK'ision.  If 
the  incision  he  ]>ro|)erly  phieed,  the  sartorins  ninx'h' comes 
into  view  ixWvv  (Hvision  ol'  tlie  i'ascia,  heing  recooni/cd  hy 
its  niuscuhir  tihers  rnnninii;  j)aranel  with  the  ontanoons 
incision.  It"  the  HIkts  of  the  exposed  nmscle  pass  from 
within  antl  al)ove  outward  and  downward,  or  the  reverse, 
it  may  he  known  that  the  incision  lias  been  made  too 
far  inward  or  outward,  and  tliat  the  muscle  disclosed  is 
the  adductor  niairnus  or  the  vastus  internus.  The  median 
IxM'dcr  of  the  sartorius  jnuscle  is  expose<l  hy  dissection 
with  tlie  knife,  and  the  nuiscle  raised  from  its  bed  and 
drawn  outward,  when  the  dee})  layer  of  the  fascia  lata 
will  he  seen  stretched  tightly  over  the  vessels.  After 
division  of  the  fascia  upon  the  grooved  director,  the  art- 
ery, which  in  this  situation  lies  in  front  of  the  vein,  is 
isolated   l)y   hlunt  dissection   and   ligated   (Plate  4). 

Hi.  Ligation  of  the  Femoral  Artery  in  the  Adductor 
Canal. — The  extremity  is  flexed  at  the  knee  and  the  hip 
and  slightly  abducted  and  rotated  outward  at  the  hip- 
joint.  The  cutaneous  incision  is  begun  at  the  junction 
l)etween  the  middle  and  lower  thirds  of  the  thigh  along 
the  lateral  border  of  the  sartorius  muscle  (Fig.  49,  c). 
The  dissection  advances  l)etween  the  vastus  internus  and 
the  sartorius  until  the  silvery,  fibrous  sheath  stretched 
between  the  adductor  magnus  and  the  vastus  internns 
comes  clearly  into  view.  The  fibers  of  this  sheath,  which 
form  the  covering  of  the  adductor  canal,  are  divided, 
when  the  artery  is  disclosed.  The  vein  lies  behind  the 
artery,  with  which  it  is  intimately  related  by  connective 
tissne  (Plate  5). 

Ligatii)n  of  the  internal  saphenous  vein  has  been  recommended  by 
Trendelenbiirs  in  the  treatment  of  varicose  veins  of  the  lower  extremi- 
ties. A  cutaneous  incision  about  3  cm.  (1  in.)  long  is  made  on  tlu-  inner 
aspect  of  the  thigh  at  the  junction  of  its  middle  and  ui)per  thirds.  A 
catgut  ligature  is  thrown  around  the  isolated  vein  and  the  extremity  ele- 
vated in  (jrder  tliat  the  blood  may  njake  its  exit.  Two  ligatures  are 
applied  to  the  vein  and  the  vessel  is  divided  between  them.  The  small 
Wound  in  the  skin  is  closed  by  sutures. 

Ligation  of  the  Popliteal  Artery. — The  popliteal  space 


78 


OPERA TIVE  S URGER  Y. 


Plate  6.— Exposure  of  the  Popliteal  Artery.    Left  Lower 
Extremity,  Flexor  Aspect. 

S,  semimembranosus ;  B,  biceps  femoris  ;   T,  triceps ;  I,  branches  of  the 
sciatic  nerve  ;  A,  popliteal  artery ;   V,  popliteal  vein. 


is  bounded  above  by  the  biceps  femoris  and  the  semi- 
membranosus muscles,  and  below  by  the  two  heads  of  the 


Fig.  50.— The  muscles  of  tbe  popliteal  space  and  of  the  calf  of  the 
leg:  8,  semimembranosus;  B,  biceps  femoris;  T,T,  heads  of  the  gastroc- 
nemius. 

gastrocnemius  (Fig.  50).     The  popliteal  artery  and  vein 
pass  in  the  longitudinal  axis  of  this  lozenge-shaped  space, 


Tab.     ti. 


Idh.A/ist  J-:  Reichhold,  Miinchen. 


LIGATIoy  OF    VESSELS  AV  COyTIM'lTY 


79 


tlio  artery  more  docply  tlian  the  vein  and  almost  in  con- 
tact with  tlu'  ca])sulc  of  the  knee-joint.  The  continuation 
of  the  sciatic  nerve  lies  over  the  vessels  and  almost  imme- 
diately beneath  the  superticial  fascia. 


Fig.   51. — Cutaneous  incision  for  ligation  of  the  popliteal  artery. 

For  the  ligation  of  the  popliteal  artery  the  patient  is 
placed  in  the  prone  position,  and  a  longitudinal  incision 
is  made  in  the  middle  line  of  the  popliteal  sj)ace  (Fi«r. 
51).     After  division  of  the  skin  and  the  fascia  the  tihial 


80  OPERATIVE  SURGERY. 

nerve,  which  is  superficial,  is  exposed.  This  nerve  serves 
as  a  guide  to  the  vessels,  whicli  will  be  found  bv  advanc- 
ing more  deeply  into  the  fatty  connective  tissue  of  the 
popliteal  space  at  the  side  of  the  nerve.  The  vein  lies 
behind  the  artery,  with  which  it  is  intimately  connected 
bv  cellular  tissue. 

Another  way  of  reaching  the  popliteal  vessels  consists  in  entering 
the  popliteal  space  from  the  inner  aspect  of  the  lowermost  extremity  of 
the  thigh  behind  the  tendons  of  the  adductors,  between  these  and  the 
tendons  of  the  gracilis  and  the  sartorius.  The  extremity  is  flexed  at 
the  knee-joint,  adducted,  and  rotated  outward  at  the  hip-joint.  The 
adductor  tendon  can  be  felt  on  the  inner  side  above  the  inner  condyle, 
behind  which  the  skin  forms  a  slight  depression.  An  incision  is  made 
in  this  situation  in  the  long  axis  of  the  thigh,  and  after  division  of  the 
fascia  the  adductor  tendon  can  be  separated  from  the  sartorius  and 
gracilis  muscles  by  blunt  dissection.  The  popliteal  mass  of  fat  exposed 
is  entered  from  the  side,  and  the  sheath  of  the  vessels  is  found  upon  the 
floor  of  the  popliteal  space. 

Ligation  of  the  Anterior  and  Posterior  Tibial  Arteries. — 
The  muscles  of  the  leg  are  so  arranged  that  the  flexors 
lie  upon  the  anterior  surface  of  the  interosseous  ligament, 
while  upon  the  posterior  surface  lie  the  flexors.  The 
latter  are  covered  by  the  calf-muscles.  The  peronei  mus- 
cles are  grouped  about  the  fibula.  Upon  the  anterior 
aspect  of  the  leg  the  vessels  lie  directly  u})on  the  interos- 
seous ligament  and  pass  among  the  muscles  toward  the 
dorsum  of  the  foot.  Upon  the  posterior  aspect  the  ves- 
sels and  the  nerves  pass  in  the  interval  between  the  calf- 
muscles  and  the  flexors. 

The  popliteal  artery  divides  at  the  lower  border  of  the 
popliteus  muscle  into  the  tibioperoneal  trunk  and  the 
anterior  tibial  artery.  The  posterior  til)ial  artery  and 
the  peroneal  artery,  branches  of  the  tibioperoneal  trunk, 
pass  downward  between  the  superficial  and  deep  layers 
of  muscles  upon  the  flexor  aspect  of  the  leg,  separated 
from  the  calf-muscles  by  a  layer  of  fascia. 

The  posterior  tibial  artery  runs  close  to  the  tibia  and 
comes  to  lie  behind  the  internal  malleolus,  in  which  situ- 
ation, corresponding  to  the  origin  of  the  abductor  hallucis, 
it  divides  into  the  internal  and  external  plantar  arteries. 


LIGATION   OF    VESSELS  IN  CONTINUITY. 


81 


The  peroncnil  artery  runs  in  tlie  same  j)]ane  alon^  the 
fibula  toward  the  external  malleolus,  where  it  terminates 
in  several  branehes. 

The  anterior  tibial  artery  penetrates  the  interosseous 
ligament  from  the  flexor  aspcet  of*  the  leg  and  thus  comes 


-Ta 


Fig.  52.— Arrangement  of  the  muscles  of  the  leg,  anterior  aspect: 
the  arteries  lie  upon  the  interosseous  ligament  and  pass  between  the 
tibialis  anticus  muscle  {T.a.)  and  the  extensor  digitorum  {E.d.),  or  the 
extensor  hallucis  {E.h.). 

to  lie  upon  the  anterior  surface  of  the  ligament  beneath 
the  muscles.  In  this  situation  the  vessel  runs  along  the 
outer  border  of  the  tibialis  anticus  muscle  toward  the  foot 
(Fig.  52).     Arrived  at  the  dorsum  of  the  foot,  the  artery, 

6 


82  OPERATIVE  SURGERY. 

Plate  7. 

Fig.  1. — Exposure  of  the  auterior  tibial  artery  of  the  left  leg.  The 
fascia  is  opened,  and  the  tibialis  antieus  muscle  {Ja)  is  retracted  toward 
the  median  Hue,  and  the  extensor  hallucis  {E.li.)  toward  the  outer 
side.  In  the  interval  between  the  two  muscles  the  deep  perineal  nerve 
(P.jp.)  comes  first  into  view  and  behind  it  the  artery  surrounded  by  veins. 

Fig.  2. — Exposure  of  the  posterior  tibial  artery  behind  the  internal 
malleolus.  The  tortuous  artery  accompanied  by  two  veins  is  visible 
beneath  the  divided  fascia  {F). 


here  known  as  the  dorsalis  pedis,  lies  upon  the  outer  side 
of  the  tendon  of  the  extensor  hallucis  longus.  In  the 
space  between  the  metatarsal  bone  of  the  great  toe  and 
the  second  metatarsal  bone  the  artery  descends  toward 
the  sole  of  the  foot,  where  it  miites  with  the  external 
plantar  artery,  one  of  the  two  terminal  branches  of  the 
posterior  tibial  artery. 

The  anterior  tibial  artery  is  accompanied  by  the  deep 
peroneal  nerve  and  the  posterior  tibial  artery  by  the 
posterior  tibial  nerve. 

The  anterior  tibial  artery  is  ligated  typically  in  its 
course  at  a  point  corres])onding  to  the  junction  of  the 
middle  and  lower  thirds  of  the  leg,  and  as  the^  dorsalis 
pedis  upon  the  dorsum  of  the  foot.  The  posterior  tibial 
artery  is  exposed  for  ligation  in  its  course  upon  the  leg 
and  behind  the   internal  malleolus. 

In  ligating  the  anterior  tibial  artery  an  incision  is  made 
upon  the  anterior  aspect  of  the  leg  in  a  situation  cor- 
responding with  the  junction  of  its  middle  and  lower 
thirds,  a  finger's  breadth  external  to  the  crest  of  the  tibia 
(Fig.  53).  After  division  of  the  tense  and  tough  fascia  in 
the  line  of  the  cutaneous  incision,  the  dissection  is  pro- 
ceeded with  from  the  outer  side  of  the  tendon  of  the  tibialis 
antieus  muscle  between  this  and  the  adjacent  extensor 
hallucis  longus  down  to  the  interosseous  ligament.  Before 
the  vessel  is  reached  the  deep  peroneal  nerve  comes  into 
view.  Behind  this  lies  the  artery,  surrounded  by  a  net- 
w^ork  of  veins  (Plate  7,  Fig.  1).  To  facilitate  isolation 
of  the  vessel  it  is  well  to  separate  the  tibialis  antieus  and 


I 


LIGATIoy  OF   VESSELS  IN  CONTINUITY. 


83 


the  extensor  liallucis  muscles  vigorously  with  tenacula. 
In  order  to  reach  tlie  artery  readily  it  is  important  to  fol- 
low aeeurately  the  interval  Ix'twcen  the  nuisch'S,  as  other- 
wise access  to  the  vessels  will  be  attended  with  difficulty. 


1—6 


Fig.  53. — Cutaneous  incisions  for  ligation  of  the  anterior  tibial  artery  (a) 
and  the  dorsalis  pedis  artery  (b). 

Entrance  is  secured  from  the  outer  border  of  the  tibialis 
posticus  muscle. 

To  expose  the  posterior  tibial  artery  in  its  course  along 
the  leg,  a  longitudinal  incision  is  made  in  the  middle  third 
of  the  leg,  a  finger's  breadth  internal  to  the  median  border 


84 


OPERATIVE  SURGERY. 


of  the  tibia  (Fig.  54,  a).  After  division  of  the  skin  and  fascia 
the  fibers  of  the  soleus  muscle  are  freed  from  their  attach- 
ment to  the  bone,  and  the  interval  between  the  superficial 
and  the  deep  group  of  calf-muscles  occupied  by  loose  con- 
nective tissue  comes  into  view.  If  the  muscles  of  the 
calf  in  the  extent  of  the  wound  are  raised  from  their  bed 


Fig.  54.— Incisions  for  ligating  tht  i^u^iciior  tibial  artery  in  the  leg  (a) 
and  behind  the  internal  malleolus  (6). 

with  a  blunt  hook,  the  posterior  tibial  artery,  accompanied 
by  the  nerve  of  the  same  name  and  several  veins,  will  be 
found  beneath  the  layer  of  fascia  covering  the  deep  group 
of  muscles  between  the  tibialis  posticus  and  the  flexor 
hallucis  longus  muscle. 

In  the  ligation  of  the  posterior  tibial  artery  behind  the 
internal  malleolus  the  foot  is  rotated  outward  in  maximum 


LiGATiox  OF  VESSELS  IX  coyTryrrTY.       85 

degree  and  a  curved  incision  encircling  the  niallcoliis  is 
made  at  a  jX)int  midway  between  the  extremity  of  the 
internal  malleolus  and  the  me<lian  border  of  the  tendo 
Achillis  (Fig.  54,6).  If  the  til)ruus  fascia  is  ext)osed,  the 
arter)'  comes  into  view,  accompanied  by  two  veins.  After 
division  of  the  fascia  the  artery  can  be  isolated  by  blunt 
dissection.  If  the  procedure  be  properly  carried  out, 
the  muscular  sheath  of  the  tibialis  posticus,  the  flexor  hal- 
lucis  longus,  and  the  flexor  digitorura  is  not  opened.  The 
tibial  nerve  lies  to  the  outside  of  the  vessels  (Plate  7, 
Fig.  2). 

The  dorsahs  pedis  artery  is  ligated  upon  the  dorsum 
of  the  foot  in  front  of  the  ankle-joint,  the  foot  being  held 
in  strong  plantar  flexion.  The  tendon  of  the  extensor 
hallucis  is  thus  made  palpable  and  an  incision  is  made  to 
its  outer  side  and  parallel  with  it.  The  fascia  is  now 
divided,  and  in  close  relation  with  the  bone,  the  artery, 
accompanied  by  two  veins,  is  found  to  the  outer  side  of 
the  tendon  of  the  extensor  hallucis  longus. 


86  OPERATIVE  SURGERY. 

II.  Amputations  and  Enucleations. 

The  siiriDfical  removal  of  an  extremity  or  portion  of  an 
extremity  is  designated  an  amputation  when  the  separation 
is  made  in  the  continuity  of  the  bone,  and  an  enucleation 
if  the  separation  is  made  at  an  articulation.  The  soft 
parts  are  variously  divided  in  order  that  they  may  ade- 
quately cover  the  wound  left  after  division  or  separation 
of  the  bone. 

Indications. — (1)  Developmental  anomalies,  super- 
numerary fingers,  or  acquired  incorrigible  deformities 
(contractures,  atrophic  extremities). 

(2)  Injuries,  such  as  rending  or  crushing  of  the  ex- 
tremities, destruction  of  the  skin  over  a  large  area ;  in 
general,  when  restoration  of  the  function  of  the  part  seems 
to  be  excluded  by  the  degree  and  the  character  of  the 
injury. 

(3)  Caries  of  joints  in  adults,  when  conservative  opera- 
tions are  no  longer  possible,  or  when  the  articular  disease 
is  superadded  to  a  pre-existing  tuberculosis  of  the  lungs  or 
of  other  organs. 

(4)  Infections,  phlegmonous  inflammations  of  the  tis- 
sues, gangrenous  destruction  of  joints,  osteomyelitis  with 
epiphyseal  separation  and  suppuration  of  joints,  always 
when  the  morbid  process  is  not  to  be  localized. 

(5)  Neoplasms,  malignant  disease  of  bones  and  soft 
parts ;  rarely  benign  growths  also,  such  as  enchondromata 
of  the  fingers,  furnish  an  indication  for  amputation  or 
enucleation. 

(6)  Gangrene  of  the  extremities  when  a  line  of  demar- 
cation has  formed. 

(7)  Incurable  circumferential  leg-ulcers  and  elephan- 
tiasis. 

(8)  Incurable  pseudarthroses. 
Reamputation  is  indicated  in  the  presence  of — 

(1)  Neuralgia  of  the  stump,  due  to  the  presence  of 
neuromata ; 

(2)  Conical  amputation-stumps. 


AMPUTATIONS  AND  ENUCLEATIONS.  87 

In  the  performance  of  amputation  the  patient  is  so 
placed  that  tlie  member  to  be  amputated  is  conveniently 
accessible.  The  upper  extremities  are  raised  to  a  hori- 
zontal position  and  there  maintained  by  assistants,  in 
removal  of  portions  of  the  lower  extremities  the  member, 
which  is  held  horizontally,  extends  beyond  the  edge  of 
the  table.  An  assistant  grasps  the  extremity  at  its 
periplieral  end,  and  another  assistant  fixes  it  on  the 
central  side  of  the  point  of  removal. 

Provisional  control  of  hemorrhage  is  effected  during  the 
operation  either  through  digital  compression  of  the  artery 
or  by  surrounding  the  extremity  with  the  elastic  bandage 
of  Esmarch. 

Dicjital  compression  is  only  available  when  the  artery 
can  be  compressed  against  a  firm  base,  as  a  bone. 
Thus,  the  femoral  artery  is  compressed  against  the  hori- 
zontal branch  of  the  pubic  bone  at  the  point  where  it 
passes  under  Poupart's  ligament ;  the  subclavian  artery  is 
compressed  in  the  supraclavicular  fossa  against  the  first 
rib. 

In  controlling  hemorrhage  by  means  of  the  elastic 
bandage  of  Esmarch  the  extremity  is  held  vertically  for 
a  short  time  to  facilitate  the  escape  of  blood  by  gravi- 
tation, and  is  then  surrounded  by  an  elastic  bandage  or 
an  elastic  tube  above  the  point  of  proposed  operation. 

Position  of  the  Operator. — If  the  operator  be  right- 
handed,  he  takes  such  a  position  that  the  member  to  be 
amputated  is  upon  his  right.  In  amputations  of  the  right 
upper  extremity  the  member  is  abducted  and  raised  to  a 
horizontal  position.  The  operator  stands  upon  the  outer 
side,  with  his  fiice  directed  toward  the  feet  of  the  patient. 
In  amputations  of  the  left  upper  extremity  the  operator 
stands  between  the  trunk  of  the  patient  and  the  abducted 
arm,  with  his  face  directed  toward  the  patient's  head.  In 
amputations  of  the  right  lower  extremity  the  operator 
stands  upon  the  outer  side,  and  in  operating  upon  the  left- 
side between  the  abducted  lower  extremities  of  the  patient. 
The  operator  stands  with  his  right  foot  slightly  in  advance 


88  OPERATIVE  SURGERY. 

and  supports  himself  with  his  k'ft  hand  upon  the  stump 
wliile  making  the  incisions  with  his  right. 

Steps  of  the  Operation. — The  operation  inchides  the 
following  four  steps  : 

(1)  Division  of  the  skin  and  the  muscles ; 

(2j  Removal  of  the  part,  sawing  through  the  bone ; 

(3)  Control  of  hemorrhage  bv  ligation  of  the  vessels  ; 
and 

(4)  Treatment  of  the  wound. 

The  divmon  of  the  partfi  is  so  effected  that  after  removal 
of  the  amputated  part  union  of  the  ^vound  by  suture  is 
possible,  the  stump  is  adequately  covered  by  the  soft  parts, 
and  the  cicatrix,  especially  following  amputations  of  the 
lower  extremity,  is  favorably  situated.  The  soft  parts  are 
divided  more  or  less  transversely  to  the  long  axis  of  the 
member  (circular  incision),  or  flaps  are  formed  from  the 
soft  tissues,  which,  after  completion  of  the  amputation,  may 
be  brouo'ht  too;ether  and  united.  An  intermediate  mode 
of  procedure  between  the  two  is  known  as  racket  or  oval 
incision. 

Circular  Incision. — In  accordance  as  the  soft  parts  are 
to  be  divided  transversely  or  obliquely  to  the  long  axis 
of  the  part  to  be  amputated  a  distinction  is  made  between 
the  transverse  and  the  oblique  circular  incision.  The 
division  of  the  soft  tissues  down  to  the  bone  may  be 
effected  by  a  single  incision,  or  the  skin  and  the  muscles 
may  be  divided  at  different  layers  by  two  incisions.  The 
first  method,  which  has  been  attributed  to  Celsus,  has 
only  a  limited  field  of  application.  The  second  (J.  L. 
Petit,  Cheselden)  was  originally  practised  in  such  a  way 
that  the  skin  was  first  divided  in  a  circular  manner.  The 
muscles  were  then  divided  by  a  second  more  proximal  in- 
cision, while  retraction  was  practised.  This  form  of 
incision  in  two  steps  is  thus  but  a  modification  of  the 
procedure  of  Celsus. 

A  better  purpose  is  served  by  dividing  the  skin  circu- 
larly at  some  distance  toward  the  periphery  from  the 
point  at  which  the  amputation  is  to  be  made.     To  this 


AMPUTATIOyS  AXD  EXLT'LEATIOXS. 


89 


AMPUTATIONS  AND  ENUCLEATIONS. 


91 


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r=3 


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AMPUTATIONS  AND  ENUCLEATIONS. 


93 


AMPUTATIONS  AND  ENUCLEATIONS.  95 

end  tlio  knife  is  n])|)lie<l  upon  its  hocl,  with  its  point 
(liix'c'tccl  toward  the  ojH*rator,  and  carried  around  the 
lower  cireuniference  of  the  member  (Fi^.  55).  The  knife 
is  now  a])plied  with  its  heel  at  the  beginning  of  the  incision 
already  made,  and  its  point  directed  from  the  operator  and 
carried  around  tlie  upper  circumference  of  the  member  in  an 
opposite  direction.  There  thus  results  a  circular  incision 
formed  of  two  conjoined  semicircular  ones.  When  the 
skin  throughout  the  entire  circumference  has  been  evenly 
divided  down  to  the  nuiscular  fascia  it  is  dissected  all 
around  from  the  subjacent  tissues  in  a  central  direction,  so 
that  there  results  a  hollow  cylinder  or  cuff  constituted  of 
skin  and  subcutaneous  connective  and  fatty  tissue.  In 
the  dissection  of  this  cuff  the  operator  grasps  the  margin 
of  the  wound  from  above  with  thumb  and  index-finger  at 
a  point  most  remote  from  him  and  proceeds  to  separate  it 
from  the  subjacent  tissues.  The  fibers  uniting  the  skin 
and  the  fascia  are  divided  by  strokes  of  the  knife  held 
vertically  to  the  underlying  structures  (Fig.  56).  The 
adjacent  skin  is  now  grasped  and  separated  from  the  sub- 
jacent tissues  in  the  same  manner.  The  operator  in  this 
w^ay  gradually  encircles  the  entire  circumference  of  the 
extremity.  When  the  starting-point  has  been  reached 
the  process  of  detachment  is  renewed,  and  this  is  repeated 
until  a  cuff  of  sufficient  size  has  been  obtained  that  can  be 
everted  and  turned  on  itself. 

It  is  important  that  the  line  at  which  the  cuflp  is  folded 
over  should  occupy  a  plane  at  right  angles  to  the  longi- 
tudinal axis  of  the  member.  The  size  of  the  cuff  will  be 
governed  l)y  the  diameter  of  the  member  to  be  amputated. 
In  general  the  cutaneous  incision  will  lie  toAvard  the 
periphery  at  a  distance  from  the  plane  of  amputation 
equalling  about  two-thirds  of  the  diameter  of  the  ex- 
tremity at  the  level  of  this  plane. 

The  muscles  are  divided  with  long  strokes  of  the  am- 
putatioii-knife  at  the  level  where  the  cuff  of  skin  has 
been  folded  over  in  such  a  way  that  the  cut  surfaces  of  the 
muscles   form   an  even   plane.     In   the   division  of  the 


96  OPERATIVE  SURGERY. 

muscles  the  knife  is  held  in  the  same  manner  as  in 
making  the  cutaneous  incision  (Figs.  55  and  57).  Experi- 
ence will  teach  the  proper  degree  of  pressure  and  of 
traction  to  be  exercised.  The  knife  is  applied  upon  its 
heel  and  pressure  exerted  against  the  resisting  mass  of  mus- 
cles, the  operator  at  the  same  time  making  traction  toward 
himself.  In  this  way  the  muscles  are  divided  with  a 
single  stroke  at  the  margin  of  tlie  cuff,  the  knife  being 
drawn  from  heel  to  toe  in  a  horizontal  plane  toward  the 
operator.  Without  changing  the  position  of  the  knife  the 
direction  of  pressure  is  reversed,  the  blade  being  applied 
with  full  force  and  passing  from  toe  to  heel,  w^hile  the 
hand  is  raised,  the  remainder  of  the  muscular  tissue  upon 
the  lower  portion  of  the  circumference  and  upon  that 
portion  most  distant  from  the  operator  being  divided. 
Next  the  muscles  of  the  upper  portion  are  divided.  To 
this  end  the  knife  is  applied  from  above  w^ith  its  heel  in 
the  beginning  of  the  incision  and  its  point  directed  from 
the  operator,  and  the  muscles  are  cut  through. 

In  amputations  of  the  leg  and  the  forearm  the  division 
of  the  structures  between  the  two  bones  requires  a  special 
procedure.  After  the  muscles  have  been  divided  circu- 
larly in  the  manner  described,  a  small  knife  is  introduced 
into  the  interosseous  space,  with  its  edge  at  right  angles  to 
the  bone,  and  the  contained  structures  are  severed.  The 
details  of  this  procedure  are  described  at  length  under 
Amputations  of  the  Leg. 

Flap-inGision. — In  this  method  of  operating  the  soft 
parts  are  incised  in  the  form  of  flaps,  w^iich  are  used  to 
cover  the  stump.  Flaps  may  be  made  in  various  shapes — 
e.  g.,  semicircular,  tongue-shaped  with  parallel  margins 
and  rounded  corners,  etc.  They  consist  of  either  skin  or 
skin  and  muscular  tissue,  or  skin  and  periosteum,  and  are 
accordingly  designated  tegumentary  flaps,  musculotegu- 
mentary  flaps,  tegumentary-periosteal  flaps,  etc.  Portions 
of  bone  may  also  be  included  with  the  skin  in  flaps  and 
be  so  adapted  to  the  wound-surface  as  to  contribute  to  the 
formation  of  a  satisfactory  stump.     Flaps  are  always  con- 


A.yfPrTATIoyS  AXD   KyUCLEATIOSS. 


97 


AMPUTATIOyS  AXD  EyUCLEATIOXS. 


99 


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AMPUTATIONS  ASD  ESUCLEATIOSS. 


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AMPUTATIONS  AND  ENUCLEATIONS, 


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AMPUTATIONS  AND  ENUCLEATIONS. 


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AMPUTATIOXS  AND  EXUCLEATIOyS.  107 

stituted  of  a  greater  amount  of  structure  at  their  base 
than  at  their  free  extremity.  The  stump  is  covered  with 
a  single  iiap  (Lowdham,  Verduin)  or  with  two  flaps 
(Ravaton).  Flaps  may  be  made  of  equal  or  of  unequal 
size,  and  in  accordance  with  their  situation  they  are  desig- 
nated anterior,  lateral,  or  posterior. 

The  formation  of  flaps  may  be  effected  by  incisions 
from  without  inward  (Langenbeck ),  or  the  reverse  by 
cutting  from  the  base  toward  the  peripheiy  (transfixion). 
Under  the  conditions  first  indicated  the  shape  of  the  flap 
is  outlined  with  the  knife,  and  the  skin  and  fascia  in  this 
distribution  divided  down  to  the  muscular  layer,  when  the 
flap  retracts  somewhat.  From  the  line  of  retmction  the 
muscular  layer  is  divided  with  long  strokes  of  the  knife 
down  to  the  bone,  when  the  whole  flap  can  be  turned 
back.  AVhen  a  tegumentary  flap  is  to  be  formed  the  skin, 
after  the  outline  of  the  flap  has  been  made  with  the  knife, 
is  grasped  with  a  pair  of  toothed  forceps  or  a  tenaculum, 
and  raised,  being  progressively  separated  from  the  sub- 
jacent structures. 

In  making  flaps  by  transfixion  smooth  wound-surfaces 
are  afforded.  One  of  two  modes  of  procedure  may  be 
followed.  The  flap  may  be  formed  by  direct  transfixion, 
the  knife  being  thrust  transversely  through  the  muscles 
close  to  the  bone  and  cuttino;  toward  the  skin.  In  the 
other  mode  of  procedure  the  operator  outlines  the  shape 
of  the  flap  with  the  knife,  at  the  same  time  dividing  the 
fascia  so  that  the  flap  retracts  somewhat.  The  knife  is 
now  introduced  at  the  base  of  the  flap  in  tlie  manner 
already  described  and  carried  through  the  muscles  to  the 
end  of  the  flap,  where  it  makes  its  exit.  By  this  means 
is  attained  the  most  advantageous  distribution  of  the 
muscles  in  the  flap,  which  at  its  peripher}^  will  consist 
only  of  skin  and  fat  (Figs.  59  and  G2). 

When  two  flaps  have  been  formed  in  one  of  the 
ways  described,  they  are  folded  over  and  the  mnsciilar 
tissues  yet  attached  to  the  bone  are  divided  by  a  circular 
incision  (Fig.  62).     In  amputations  of  the  leg  or  of  the 


108 


OPERATIVE  SURGERY. 


forearm  the  muscular  tissue  in  the  interosseous  space 
should  be  divided  according  to  established  rules  before 
the  bones  are  sawed  through. 

The  oval  incision  results  when  the  circular  incision  is 
joined  at  some  point  of  its  periphery  by  a  longitudinal 
incision,  which,  like  the  circular  incision,  passes  through 
the  periosteum  down  to  the  bone.  The  apex  of  the  oval 
is  placed  either  upon  the  extensor  asj^ect  of  the  joint  or 
upon  one  of  its  lateral  aspects.  From  it  pass  in  a  periph- 
eral direction  two  diverging  incisions,  which  meet  trans- 


FlG.  63. — Oval  incision  for  amputation  of  the  index-finger  at  the 
metacarpophalangeal  articulation. 

verselv  at  an  opposite  point  of  the  periphery  (method 
of  Scoutetten).  The  form  of  the  wound  corresponds 
with  that  of  a  heart,  the  apex  of  the  oval  being  the  most 
central  portion.  The  bone  is  removed  at  this  level  (Fig. 
63).  After  union  by  suture  the  wound  is  linear.  The 
oval  incision  is  employed  especially  in  enucleation  of 
fingers  and  toes ;  less  commonly  in  enucleation  of  the 
shoulder-joint  or  the  hip-joint. 

Division  of  the  Bone. — After  complete  division  of  the 
soft  parts  and  incision  of  the  periosteum  the  latter,  in  the 


A  MP  VTA  rioxs  A  M)  j.y  U(  7.  /•;.  1  Tioys.         1 09 

area  of  tlu^  incision,  is  carefully  detached  from  tlic  hone 
for  a  short  distance  in  a  proximal  direction  with  a  rasj)a- 
tory,  in  order  that  a  suilicient  surliice  be  exposed  lor  the 
application  of  the  saw  and  the  periosteum  is  not  crushed 
or  torn  from  its  attachments,  and  primary  union  be  thereby 
]>revented.  In  sawiuii'  throuirh  the  bone  care  should 
be  taken  that  the  division  is  etfected  as  far  from  the 
periphery  as  possible ;  that  the  sawed  surface  is  at  right 
angles  to  the  louiiitudinal  axis  of  the  bone  ;  and  that  the 
soft  parts  are  protected  from  all  injury.  The  muscles 
are  drawn  with  tenacula  out  of  reach  of  the  saw  or 
the  stump  is  wrapped  in  suitable  compresses  and  thus 
protected. 

In  applying  the  saw  the  nail  of  the  thumb  of  the  left 
hand  is  placed  vertically  upon  the  denuded  bone  (Fig. 
58),  and  the  support  thus  atibrded  is  used  as  a  guide  for 
the  blade  of  the  saw.  At  first  the  saw  is  manipulated 
without  pressure.  Only  after  a  groove  has  been  formed 
in  the  bone  may  the  sawing  be  proceeded  with  more 
mpidly,  with  the  application  of  a  certain  degree  of  press- 
ure. An  assistant,  stationed  at  the  periphery,  holds  the 
extremity  in  a  position  of  extension  and  aims  to  keep  the 
sawed  surfaces  apart  in  order  that  the  blade  of  the  instru- 
ment shall  not  become  impacted.  The  irregular  edges  of 
the  divided  bone  are  trimmed  by  means  of  bone-forceps, 
and  small  projections  are  cut  off. 

After  complete  removal  of  the  amputated  part  atten- 
tion is  directed  to  the  definite  control  of  hemorrhage.  The 
main  arterial  and  venous  trunks,  recognizable  by  their 
position,  are  isolated  in  the  stump  with  the  aid  of  two 
pairs  of  dissecting-forceps,  clamped  in  sliding-forceps,  and 
ligated.  In  addition  to  the  main  arterial  branches  all 
vessels  that  can  be  seen  running  in  the  connective-tissue 
interstices  of  the  muscles  are  also  ligated.  The  Esmarch 
bandage  can  now  be  freed,  and  it  may  be  necessary  to 
apply  additional  lig-atures.  Parenchymatous  hemorrhage 
is  controlled  by  compression. 

The  care  of  the  icound  has  for  its  object  accurate  ap- 


110  OPERATIVE  SURGERY. 

proximation  of  the  wound-surfaces,  with  the  avoidance  of 
dead  spaces,  as  well  as  exact  approximation  of  the  margins 
of  the  skin.  The  muscles  may  be  separately  united  by 
buried  sutures  or  large  areas  of  surface  by  means  of 
gauze-pad  sutures,  while  the  skin  is  closed  by  superficial 


Fig.  64. — Cutaneous  suture  after  amputation  of  the  leg  through  a 
circular  incision. 

knotted  sutures,  or  by  a  continuous  suture  (Figs.  64  and 
65). 

If  it  has  been  possible  to  effect  the  amputation  under 
complete  aseptic  conditions,  the  wound  may  be  closed 
entirely  by  suture ;  otherAvise  drains  may  be  brought  to 
the  surface  out  of  the  depth  of  the  wound.  A  like  pur- 
pose may  be  served  by  the  introduction  of  strips  of  sterile 
or  antiseptic  gauze. 

In  the  performance  of  exarticulation  the  same  general 
principles  may  be  observed  as  in  the  performance  of 
amputation.  The  operator  stands  at  the  periphery  of  the 
extremity,  holding  the  part  to  be  removed  in  the  left 
hand,  while  the  exarticulation  is  eifected  with  the  right. 
In  the  majority  of  cases  the  joint  is  opened  from  its  ex- 
tensor aspect.  Flap  and  oval  incisions  are  generally 
employed,    less    commonly   circular   incisions,    with   the 


A  MP  I TTA  TIONS  A  NJ)   KN  UL  7>  KA  TIONS. 


Ill 


formation  of  a  cuff.  T\w  Haps  are  so  formed  that  their 
base  c'orres]K)n(ls  with  tlie  phme  of  tlie  joint  at  which  the 
separation  is  to  be  made.  As  a  rub',  Haps  of  unusual  siz(.' 
are  made.  Upon  that  side  of  tlie  joint  on  wliich  the  cap- 
sule is  first  opened  the  flap  may  l)e  made  by  transfixion 
or  by  dissection  from  without  inward.  AVhen  the  exar- 
tieulation  is  completed  the  soft  j)arts  upon  the  opposite 
side  of  the  joint  are  diyided  from  within  outward.     To 


^'" 


Fig.  65. — Cutaneous  suture  after  flap-amputation  of  the  thigh, 

this  end  the  operator  draws  upon  the  extremity,  grasped 
with  the  left  hand  and  already  freed  at  the  articulation, 
in  such  a  way  that  the  bridge  of  skin  still  uniting  the 
part  wnth  its  central  attachment  is  made  smootli  and 
tense.  The  knife  is  introduced  into  the  wound  and 
divides  the  tissues  transversely.  In  making  the  division 
care  should  be  taken  that  the  muscles  are  first  divided 
and  then,  somewhat  further  toward  the  periphery,  the 


112  OPERATIVE  SURGERY. 

skin.  The  methods  of  performing  exarticulation  are  in 
part  so  carried  out  that  Avith  the  last  incision  of  the  knife, 
which  passes  from  the  Avound  and  forms  tlie  flap,  the 
main  vessels  are  severed.  During  the  process  of  division 
the  artery  may  be  closed  by  pressure  with  the  finger  in 
the  wound.  A  method  of  exarticulation  (Esiliarch)  often 
employed  with  large  joints  consists  in  circular  division  of 
the  soft  parts  in  the  upper  third  of  the  extremity  down  to 
the  bone  after  application  of  the  Esmarch  bandage.  The 
bone  also  is  divided  at  the  level  of  the  incision  through 
the  muscles.  After  ligation  of  the  vessels  the  constrict- 
ing band  is  removed.  A  longitudinal  incision  is  made 
through  the  soft  parts  down  to  the  bone  from  the  joint  to 
the  primary  wound  in  such  a  w'ay  that  large  vessels  and 
nerves  are  not  divided.  With  the  wound  thus  made 
held  open  by  means  of  hooks,  the  joint  is  opened  and  the 
remainder  of  the  bone  removed  with  the  utmost  care. 
This  combination  of  circular  and  longitudinal  incisions 
constitutes  a  variety  known  as  the  racket-incision. 

Amputations  and  Bxarticulations  of  the  I/Ower 
Extremity. — Amputation  of  the  Leg. — The  removal  of 
the  leg  may  be  undertaken  at  varying  levels.  It  was 
formerly  the  custom  to  amputate  the  leg  under  all  cir- 
cumstances in  its  upper  third  at  the  site  of  election. 
This  method  had  for  its  object  the  use  of  a  wooden  leg, 
upon  which  the  flexed  knee  Avas  comfortably  received 
after  the  wound  had  healed.  At  present,  hoAvever,  the 
principle  is  folloAved  to  be  as  conservative  as  possible  in 
amputations  of  the  leg,  and  in  the  remoA^al  to  take  the 
greatest  care  of  tlie  healthy  portion  of  the  extremity. 
For  this  reason  amputations  are  no  longer  performed  at 
the  site  of  election,  but  at  the  site  of  necessity. 

Among  the  methods  of  amputation  of  the  leg  employed 
are  the  circular  incision  in  two  steps,  Avith  the  formation 
of  a  cufF;  and  A^arious  forms  of  flap-operations:  tAvo 
lateral  tegumentary  flaps;  two  lateral  musculotegu- 
mentary  flaps  ;  one  anterior  tegumentary  periosteal  flap  ; 
and  a  posterior  short  musculotegumentary  flap  from  the 


- 1  ^frl  'T.  1 77' K\s  . I  yj}  j:y i  v  lk. i  tjoxs.  1 1 3 

calf  (Heine).  A  simple  larire  ninsculotegumentarv  flap 
from  the  substance  of  the  calf  also  may  serve  to  cover  the 
stump. 

Amputation  of  the  Leg  with  a  Circular  Incision  in  Two 
Steps. — An  assistant  rotates  the  leg  towanl  the  operator 
and  a  circular  incision  is  made  throuirh  the  skin,  begin- 
ning at  a  [)oint  most  remote  from  the  ojx*rator,  and  pro- 
gressing toward  himself,  until  the  entire  circumference  of 
the  part  is  dissected  and  a  cutf  is  formed.  When  this 
has  been  separated  for  a  sufficient  distance  all  around  and 
folded  back  the  layer  of  muscles  is  divided.  The  incision 
through  the  muscles  of  the  calf  is  made  in  three  steps. 
Finally  the  muscles  upon  either  side  of  the  interosseous 
ligament  are  divided.  This  complex  incision  should  be 
made  exactly  in  the  same  plane,  .so  that  the  vessels  are 
not  divided  at  varying  levels. 

In  making  the  figure-of-eight  incision  the  knife  is 
placed  horizontally,  with  its  heel  upon  the  upper  surface 
of  the  tibia,  so  that  its  pointed  extremity  is  directed 
toward  the  operator.  It  is  steadily  held  in  a  horizontal 
position  and  drawn  from  heel  to  toe,  introduced  into  the 
interosseous  space  close  to  the  tibia  up  to  its  handle,  and 
the  soft  tissues  between  the  two  bones  divided.  The 
fibula  being  reached,  the  knife  is  drawn  from  heel  to  toe 
around  this  bone  and  passed  horizontally  ag-aiu  into  the 
interosseous  space,  with  its  point  directed  from  the  ope- 
rator and  its  blade  upward,  dividing  any  remaining  mus- 
cular fibers  from  the  fibula  toward  the  tibia.  The  ope- 
rator now  introduces  the  index-finger  and  t-he  thumb  of 
his  right  hand  into  the  wound  and  grasps  the  intero.sseous 
ligaments  to  assure  himself  that  all  of  the  muscles  have 
been  transversely  divided.  Before  the  saw  is  used  the 
assistant  rotates  the  member  inward.  The  periosteum  is 
detached  from  the  bone  with  the  raspatory-  at  the  line  of 
division.  The  saw  is  applied  upon  the  til)ia  in  such  a 
manner  that  the  fibula  also  is  brought  within  the  range  of 
its  action.  A  groove  is  first  carefully  sawed  in  the  tibia, 
and  when  the  blade  of  the  saw  has  thus  secured  a  good 
d 


114  OPERATIVE  SURGERY. 

Plate  8.— Transverse  Division  of  the  Right  Leg  in  its 
Middle  Third. 

t,  tibia;  /,  fibula;  E,  group  of  extensors  (tibialis  auticus,  extensor 
digitorum  communis,  extensor  hallucis)  ;  S,  soleus;  G,  gastrocnemius; 
Tp.,  tibialis  posticus;  Pi:,  perouei ;  Ta.,  anterior  tibial  artery,  with  the 
corresponding  vein  and  the  deep  peroneal  nerve ;  T,  posterior  tibial 
artery,  with  the  corresponding  veins  and  the  posterior  tibial  nerve ;  P, 
peroneal  artery  and  vein. 

grasp  the  fibula  also  is  brought  within  the  sphere  of  its 
activity  and  both  bones  are  divided  simultaneously  (Fig. 
58). 

The  stump  thus  made  shows  the  cross-section  of  the 
two  bones,  with  the  interosseous  ligaments  stretched 
between  them.  Anteriorly,  lying  upon  the  ligament,  is 
the  group  of  extensors,  while  upon  the  opposite  side  lie 
the  flexors.  Surrounding  the  fibula  the  peroneal  group  of 
muscles  is  visible.  The  powerful  mass  of  the  calf-muscles 
forms  the  most  superficial  layer  upon  the  flexor  aspect. 
Between  this  and  the  flexors  pass  the  posterior  tibial  and 
peroneal  arteries.  Lying  upon  the  anterior  aspect  of  the 
interosseous  ligament  is  the  anterior  tibial  artery.  The 
center  of  the  field  is  occupied  by  the  tibialis  posticus  mus- 
cle, which  is  a  useful  landmark  in  looking  for  the  vessels. 
In  front  of  this,  but  separated  by  the  interosseous  liga- 
ment, is  the  anterior  tibial  artery,  and  closely  behind  it 
are  the  posterior  tibial  and  peroneal  arteries  to  the  fibular 
and  tibial  sides  respectively. 

Flap-amputations  of  the  Leg. —  Two  Lateral  Tegument- 
ary  Flaps  of  Equal  Size. — The  base  of  the  flaps  corre- 
sponds with  the  level  at  which  the  bones  are  to  be  di- 
vided. Anteriorly  the  margins  of  the  flaps  meet  in  the  line 
of  the  crest  of  the  tibia.  The  shape  of  the  flaps  is  out- 
lined Avith  the  knife  introduced  down  to  the  fascia,  when 
the  flaps  are  dissected  from  the  subjacent  structures  and 
turned  back  (Fig.  61).  The  incisions  through  the  mus- 
cles are  to  be  made  in  the  typical  manner  described  at 
right  angles  to  the  axis  of  the  extremity.  The  muscles 
of  the  calf  are  divided  in  three  steps ;  then  those  of  the 


Tab.     8. 


0. 


LUh.  Anst  /.'  HeuMwld.  Muncheti 


AMPUTATIONS  AND  ENUCLEATIONS. 


115 


interosseous  space  ])y  the  fi^iire-of-ei<;lit  incision;  finally 
{\\v  hone  is  divided  in  the  manner  descrihech  To  prevent 
tlic  ])r()jcction  of  the  sharp  anterior  crest  of  the  tihia  after 
division  Avith  the  saw  this  j)roniinence  is  either  broken 
ofl'  witli  forceps  or  sawed  off*.  To  this  end  the  crest  is 
sawed  into  in  an  o])liqiie  direction,  from  above  downward 


Fig.  66. — Incisions  for  amputation  of  the 
leg:  a,  circular  incision  for  amputation  at 
the  site  of  election  ;  6,  lateral  flap-incisions. 


and  backward,  for  some  distance,  before  the  bone  is 
removed.  A\'hen  the  tibia  is  now  divided  transversely  a 
])ortion  of  the  bone  at  the  crest  falls  out  and  the  previous 
prominence  is  removed. 

Two  Lateral  3Iusculotegumentary  Flaps. — The  shape  of 
the  flaps  is  the  same  as  that  just  described.     An  incision 


116 


OPERA  TIYE  S URGER Y. 


is  made  through  the  skin  and  the  fascia  down  to  the  mus- 
cle. After  the  skin  has  been  retracted  the  flaps  are  formed 
either  by  transfixion  or  by  incision  from  without  inward. 
AVhen  the  flaps  are  folded  back  the  muscles  are  divided 


Fig.  67.  Fig.  68. 

Figs.  67,  68. — Cutaneous  incisions  for  amputation  of  the  leg,  after  Heine : 
showing  anterior  and  lateral  aspects. 

bv  a  figure-of-eio^ht  incision  and  the  bone  is  sawed  through 
at  the  level  of  the  base  of  the  flaps. 

Anterior  Long  Tegumentary  Periosteal  Flop,  with,  a  Pos- 
terior Short  JIusculotegumeniari/  Flap  (Heine). — A  broad 
quadrangular  flap  with  rounded  corners  is  made  upon  the 
anterior  aspect  of  the  leg  (Figs.  67  and  6S).    In  the  situa- 


A  Mr  I  'TA  Tioys  A  M)  EX  I  X'LEA  TIOSS.  1 1 7 

ium  to  w  hieh  the  Hap,  after  diviHon  of  the  skin,  i.s  retraeted 
tile  jH'rior»teuni  of  tlie  anterior  >iirfa(e  nf  the  til>ia  is  inci>e<l 
traiisvei'sely,  parallel  with  the  hjwer  border  ol  the  tiap. 
The  skin  upon  either  side  of  the  flap  is  dissected  toward  tlie 
tihia  from  the  subjacent  tissues,  and  the  periosteum  of  the 
tibia  0(»rres])<)ndinir  to  the  lateral  boundaries  of  the  Hap  is 
divided  longitudinally.  In  the  process  of  dissectinjir  the 
flap  the  periosteum  is  detached  from  the  bone  i>y  means 
of  a  raspatory  and  tluis  retains  its  connection  with  the 
freed  skin.  After  the  anterior  flap  has  been  dissected  to 
its  base  the  bone  is  raised  and  a  shorter  arched  flap  con- 
sisting: of  the  skin  and  the  muscles  of  the  calf  is  formed 
u]X)n  the  |X)Steri(ir  aspect  of  the  leg  by  an  incision  from 
without  inward.  The  muscles  of  the  interosseous  space 
are  then  divided  and  the  bones  are  sawed  through  in  the 
usual  manner. 

A  ft'uiffle  lateral  jfap  is  made  correspond i ugly  longer  and 
with  a  broader  base.  It  may  be  constituted  of  skin,  on 
the  inner  side  of  skin  and  periosteum,  or  finally  of  skin 
and  muscle.  When  the  tiap  has  been  dissected  a  circular 
incision  through  the  skin  is  made  upon  the  opposite  por- 
tion of  the  circumference  of  the  leg  unitintr  the  extremi- 
ties  of  the  flap  and  after  retraction  of  this  the  muscles  are 
divided  in  the  usual  manner. 

To  increase  the  su})poning  power  of  the  stump  follow- 
ing amputation  of  the  leg  Bier,  after  healing  of  the  woimd, 
removes  a  wedge-shaped  portion  of  bone  above  the  level 
of  the  stiunp,  so  that  the  lower  extremity  of  the  latter  can 
be  turned  forward  and  upward  through  an  arc  of  ninety 
degrees  and  be  permitted  to  unite  in  this  position.  By 
this  means  closure  of  the  medullary  cavity  is  efl^c^'ted  and 
the  supporting  surface  is  formed  of  healthy,  well-padded 
skin,  free  from  cicatrices,  whose  muscles  do  not  undergo 
atrophy  by  reas<»n  of  preserving  their  natund  attachment 
to  the  bone.  The  principle  upon  which  the  method  is 
based  is  illustrated  l)y  the  accomi)anying  diagrammatic 
representation  (Fig.  69).  The  medullary  cavity  of  the 
divided  bone  may,  according  to  Bier,  be  closed  also  with 


118 


OPERATIVE  SURGERY. 


a  loose  piece  of  periosteum  or  Avith  a  foreign  body,  such  as 
stanniol-paper. 

Supramalleolar  Amputation  of  the  Leg  by  Syme's 
Method. — The  ankle-joint  is  opened  and  the  bones  of  the 
leg  divided  just  above  the  malleoli  and  the  wound  covered 
Avith  a  cutaneous  flap  obtained  from  the  heel.  The  patient 
occupies  the  dorsal  decubitus.  The  foot  is  raised  above 
the  horizontal  and  the  operator  stands  to  its  peripheral 
side.  Grasping  and  fixing  the  foot  by  the  heel  Avith  his 
left  hand  the  operator  makes  an  incision,  ahvays  begin- 
ning on  the  left  side,  from  the  apex  of  the  malleolus  ver- 
tically toAvard   the   sole    of  the   foot,  then   transversely 


Fig.  69. — Diagrammatic    representation  of  amputation  of  the  leg  after 

the  method  of  Bier. 

through  the  sole  and  again  vertically  upward  to  the  other 
malleolus,  dividing  the  tissues  down  to  the  caicaneum 
(stirrup-incision).  A  second  incision,  nuide  over  the  an- 
terior aspect  of  the  ankle-joint  unites  the  extremities  of 
the  first,  Avith  which  it  makes  a  riglit  angle  and  it  also 
extends  down  to  the  bone.  This  incision  should  open  the 
joint  betAveen  the  trochlear  surface  of  the  astragalus  and  the 
lower  extremity  of  tlie  ti])ia  and  the  fi])ula.  In  order  to 
expose  the  joint  fully  the  lateral  ligaments  must  be  divided 
on  either  side.  The  incision  through  the  capsule  has  the 
folloAving  form  :  /  ~\ ,  the  short  limbs  passing  through 
the  lateral  ligaments.  Only  after  the  lateral  ligaments  (at 
the  outer  malleolus,  the  anterior  and  posterior  astragalo- 


AMPUTAI  loy.s  ,  1 M)  KX  UCLEA  TIONS. 


119 


fibular,  and  the  calcaneofibular ;  at  the  internal  malleolus, 
rhe  deltoid  liiranient)  have  been  divided  will  tlie  head  of 
the  astragidus  l^e  free,  even  with  .-flight  plantar  Hexion  of 
the  joint.  If  the  posterior  wall  of  the  capsule  be  divided, 
the  upper  surface  of  the  ealeaneuni  comes  into  view.  The 
tuberosity  of  the  calcaneus  is  freed  from  its  coverings  by 
vigorous  incisions  made  vertically  upon  the  bone,  with  the 
foot  bent  in  maximum  plantar  flexion  (Fig.  70j.     When 


Fig.  to. — Amputation  of  the  foot  by  the  method  of  Syme :  enucleation 
of  the  tuberosity  of  the  calcaneum  from  its  coverinors. 

the  foot  is  thus  freed  and  detached  the  lower  extremities 
of  the  tibia  and  the  fibula  are  freed  from  the  soft  tissues, 
surrounded  by  a  circular  incision,  and  sawed  through 
transverselv. 

The  operation  is  attended  with  certain  disadvantages,  the  excavated 
heel-flap  not  being  properly  adapted  to  approximation  with  the  leg,  while 
the  excavation  is  further  favorable  to  the  accumulation  of  considei-able 
quantities  of  secretion.  Although  Syme's  operation  no  longer  receives 
the  recognition  which  was  formerly  accorded  it,  it  still  deserves  con- 


120 


OPERA  TIVE  S  UR  GER  Y 


sideration,  as  it  represents  the  predecessor  of  a  number  of  admirable 

operations  (PirogotI'.  Gritty,  etc.). 

Amputation    of  the  Foot  by  the  Method  of  Pirogoflf. — 
PirogoiTs  operation  consists  in  osteoplastic  supramalleolar 


Fig.  71. — PirogoflTs  amputation:  detachment  of  the  soft  parts  from 
the  posterior  aspect  of  the  lower  extremity  of  the  leg;  the  blade  of  the 
knife  is  directed  against  the  bones. 


amputation  of  the  lee:,  with  the  formation  of  an  osseous- 
tegumentary  flap  from   the  heel.     This  procedure  over- 


A  MP  I '  TA  TIOXS  A  XP  EX  I  TIE  A  TIOXS. 


121 


comes  the  ilisiulvantairos  and  ditlit'iiltics  of  Synie's  ffpfra- 
tion  hy  not  scpanitinix  tlic  tulKTo.sity  of  the  calcaneum, 
l)nt  sawing  through  the  l)one  so  that  its  posterior  segment 
retains  its  connection  with  the  skin  and  enters  into  the 
formation  of  the  flap.  The  operator  occupies  the  same 
position  as  in  the  operation  of  Syme  and  the  incisions 
throngli  the  skin  are  made  in  a  similar  manner.  The 
operator  fixes  the  foot  with  his  left  hand  and,  beginning 
on  the  left  side,  cuts  from* the  apex  of  one  malleolus  ver- 
tically toward  the  sole  of  the  foot  (Fig.  72j,  then  trans- 


FiG.  72 — PirogoflTs  amputation  :  cutaneous  incisions. 

versely  through  the  sole,  and  again  vertically  upward  to 
the  ajX'X  of  the  other  malleolus,  dividing  the  soft  tissues 
down  to  the  bone  (stirrup-incision).  An  anterior  trans- 
verse incision  unites  the  extremities  of  the  primary  stir- 
ru|>-incision.  This  incision  divides  the  tendons  of  the 
extremities  transversely  and  opens  the  capsule  of  the 
ankle-joint.  In  order  to  open  widely  the  joint  between 
the  head  of  the  astragalus  and  the  lower  extremities  of 
the  tibia  and  the  fibula  the  lateral  ligaments  must  first  be 


122 


OPERATIVE  SURGERY. 


divided.  In  effecting  this  division,  especially  upon  the 
inner  aspect,  the  incision  should  be  made  close  to  the 
astragalus,  in  order  to  avoid  injuring  the  posterior  tibial 
artery.  After  the  joint  has  been  freely  exposed  the 
posterior  wall  of  the  capsule  comes  into  view,  after 
division  of  which  the  upper  surface  of  the  tuberosity 
of  the  calcaneum  is  exposed.  The  operator,  who  until 
now  has  stood  at  the  periphery  of  the  foot,  changes  his 


Fig.  73.— PirogoflTs  amputation  :  division  of  the  calcaneum  with  the 


saw. 


position,  grasps  the  foot  with  his  left  hand  and  applies 
the  saw  to  the  upper  surface  of  the  tuberositv  of  the  cal- 
caneum (Fig.  78).  This  process  is  divided  in  a  plane 
corresponding  to  that  of  the  stirru])-ineision,  when  the 
foot  appears  to  be  separated.  The  lower  extremities  of 
the  tibia  and  the  fibula  are  prepared  for  division  with  the 
saw,  the  soft  parts  upon  the  posterior  aspect  being  first 
dissected  close  to  the  bone.  This  incision  demands  es- 
pecial  care  iii  order  to  avoid  division  of  the  posterior 


AMPUTATIOyS  ASD  ENVCLEATIOSS. 


123 


t-  r. 


AMPrTATinxs  AXD  EXUCLEATIOXS.  125 

tibial  artery,  which  is  essential  for  the  nutrition  of  the 
heel-portion  of  the  flap.  The  surgeon  grasps  the  flap 
between  the  thunil)  and  the  index-iingcr  of  his  left  hand, 
flexes  it  backward  in  maximum  degree  and  separates  the 


Fig.  75. — Stump  left  after  PirogoflTs  amputation. 

soft  parts  from  the  posterior  aspect  of  the  tibia  in  such  a 
way  that  the  blade  of  the  knife  is  brought  in  direct  con- 
tact with  the  bone  (Fig.  71). 

Upon  the  anterior  surface  it  suffices  to  di.splace  the  ten- 
dons, when  the  bones  of  the  leg  may  be  divided  circularly 


126  OPERATIVE  SURGERY. 

just  above  the  malleoli.  In  sawing  through  the  bones 
the  leg  is  held  horizontally,  the  operator  standing  as  if 
amputating,  with  the  member  to  be  amputated  to  his 
right.  An  assistant  grasps  one  of  the  malleoli  with  Lan- 
genbeck's  forceps,  when  the  division  of  the  bone  trans- 
versely to  the  longitudinal  axis  of  the  leg  may  be  pro- 
ceeded with  (Fig.  74).  The  stumps  of  the  tendons  are 
grasped  with  forceps  and  divided  with  scissors  at  the  level 
of  the  wound.  The  vessels  are  secured  by  ligatures.  The 
only  vessels  concerned  are  the  anterior  and  posterior  tibial 
arteries.  The  first  is  readily  found  upon  the  anterior  sur- 
face of  the  tibia  at  the  side  of  the  tendon  of  the  extensor 
hallucis.  If  the  successive  steps  of  the  operation  have 
been  properly  followed,  the  posterior  tibial  artery  will  be 
found  to  have  been  divided  on  the  inner  aspect  of  the  heel- 
flap,  somewhere  about  the  middle  of  the  vertical  limb  of 
the  stirrup-incision.  In  closing  the  wound  the  heel  is 
moved  through  an  arc  of  90°  and  the  sawed  surface  of 
the  calcaneum  brought  in  simple  apposition  with  that 
of  the  tibia  or  fixed  by  bone-sutures  or  jDcrcutaneous 
pegs.  The  cutaneous  wound  is  united  transversely 
(Fig.  75). 

The  operation  of  Pirogoff  has  undeniable  advantages 
over  deep  amputation  of  the  leg,  as  exemplified  by  Syme's 
operation.  The  shortening  is  reduced  to  a  minimum  by 
the  preservation  of  the  posterior  extremity  of  the  calca- 
neum, which  forms  a  prolongation  of  the  bones  of  the 
leg.  The  strong,  well-cushioned  skin  of  the  heel  makes 
an  admirable  walking-surface,  while  the  cicatrix  does  not 
lie  within  this  area. 

Pirogoff  in  his  first  communication  upon  the  subject 
had  already  called  attention  to  the  fact  that  after  making 
the  flrst  incision  into  the  sole  of  the  foot  the  division  of 
the  calcaneus  could  be  proceeded  witli  immediately  from 
the  sole  (Figs.  76  and  77),  and  exarticulation  at  the  ankle- 
joint  next  effected.  He  also  had  made  the  suggestion  to 
give  an  oblique  direction  to  the  heel-flap  in  order  to  bring 
a  larger  portion  of  the  calcaneum  and  the   skin   of  the 


AMriTA  TlOys  AMJ  Jjy UCLEA TIONS. 


12' 


Fig.  76. — Giinther's  modification  of  Pirogoff's  amputation :  division  of 
the  calcancum  from  the  sole  of  the  foot. 


Fig.  77.— Configuration  of  the  foot  after  division  of  the  calcancum. 


AMri'TATfONS  AM>   KSrcLKATlONS.  129 

Plane  of  tiik  Sawkd  Suufacks  in  riuoooFF's  Upeuation. 


Fig.  80.— Lefort's  modification. 


AMPLTATIOyS  AM>  LMCLLATJOXS.  131 

sole  into  the  po.stiricM*  flap.  The<e  mollifications  have 
been  ('lal)(>rate(l  hy  (Jiinthcr  and   Lcfort. 

\\'liik'  the  c'litaiirnii^  incision  and  the  phines  of  the  two 
incisions  thrunuli  the  l)ones  are  at  riiiht  anirk's  to  each 
other  in  Pirogotf's  operation  (Fiu:-  "t^),  the  tul)erosity  of 
the  calcanonni  is  diviikcl  ol)liqnely  from  Ijehind  above 
forward  and  downward  in  Giintiiers  modification  ;  also, 
the  lower  extremities  of  .the  tibia  and  the  fibnla  are  not 
sej)anited  in  the  tbrm  of  a  plate,  but  in  that  of  a  wedge, 
and  in  such  a  manner  that  the  base  of  the  wedoe  corre- 
sponds  with  the  posterior  and  the  apex  with  the  anterior 
bonndary  of  the  tibia.  As  a  matter  of  course,  the  cuta- 
neous incisions  are  to  be  modified  accordinsrly.  The 
stirrup-incision  will  pass  from  the  posterior  boundary  of 
the  malleoli,  not  vertically  downward,  but  obliquely  for- 
ward toward  the  sole,  so  that  a  larger  portion  of  the  skin 
of  the  sole  is  contained  in  the  heel-flap.  The  stump  is 
thus  changed  in  so  far  that  not  only  does  the  tnl^erosity 
of  the  calcaneum  form  the  walking-surface,  but  also  a 
portion  of  the  sole,  the  natural  walking-surface,  serves  as 
a  su})port  for  the  stump. 

The  walking-surface  becomes  still  broader  if  the  calca- 
neus is  divided  almost  horizontally  in  accordance  with 
the  modification  of  Lefort  (Fig.  80).  The  stirru{>- 
incision  passes  obliquely  forward  to  Chopart's  joint,  while 
the  dorsal  incision  forms  a  flap  with  its  convexity  directed 
forward,  and  it  extends  also  to  the  line  of  Chopart's 
joint.  The  dorsal  flap  is  dissected  back,  the  ankle-joint 
opened,  and  the  calcaneum  sawed  through  from  its  tuber- 
osity forward  in  the  direction  of  the  cutaneous  incision 
into  the  calcaneocuboid  joint,  the  foot  being  held  in  a 
position  of  maximum  plantar  flexion.  The  foot  is  now 
separated  at  Chopart's  joint  and  tlie  lower  extremities  of 
the  tibia  and  fibula  are  divided  in  the  manner  described. 

Bruns  recommends  horizontal  divisi(^n  of  the  calcaneinn, 
though  in  an  arched  direction.  The  sawed  surface  of  the 
calcaneum  is  thus  concave,  while  that  of  the  tibia  pre- 
sents a  corresponding  convexity. 


132  OPERATIVE  SUBGERY. 

Tlie  limitations  of  Lefort's  modification  are  naturally 
narrower  than  those  of  the  typical  operation  of  PirogofF. 
If  the  calcaneum  is  perfectly  healthy,  and  tliis  is  a  neces- 
sary condition  for  the  employment  of  Lefort's  o]^)eration, 
it  would  beem  preferable  to  select  the  less  serious  pro- 
cedure of  exarticulation  at  Chopart's  joint. 

As  a  preliminary  step  in  the  performance  of  Pirogoflf 's  operation  di- 
vision of  the  tendo  Achillis  (AchVloteuotomy)  is  undertaken.  The  ten- 
don is  divided,  either  through  an  open  wound  or  subcutaneously,  in  a 
transverse  direction,  a  finger's  breadth  above  its  attachment  to  the  tuber- 
osity of  the  OS  calcis. 

In  performing  subcutaneous  tenotomy  the  knife  ''tenotome)  is  passed 
through  the  skin  and  the  tendon  is  divided  by  cutting  either  toward  or 
from  the  skin.  Under  the  condition  fii-st  named  the  operator  grasps  the 
tenotome,  as  a  table-knife  is  held  in  paring  fruit,  with  the  flexed  four 
fingers  of  the  right  hand,  while  the  thumb  is  supported  on  the  heel  (Fig. 
&lj  ;  the  knife  is  passed  from  right  to  left  in  front  of  the  tendon.  The 
latter  is  subjected  to  passive  tension  and  is  divided  by  short  rocking 
movements  of  the  knife  toward  the  thumb,  which  is  placed  upon  the 
tendon  as  a  guide  and  to  aftord  resistance  (Fig.  62).  The  jerk  with 
which  the  extremities  of  the  divided  tendon  separate  indicates  the 
completion  of  the  operation. 

When,  on  the  other  hand,  the  tendon  is  to  be  divided  from  without 
inward  the  foot  is  so  adjusted  that  the  tendon  is  completely  relaxed. 
The  tenotome  is  grasped  between  the  thumb,  the  index,  and  the  middle 
finger  and  introduced  upon  the  flat,  from  right  to  left,  between  the  skin 
and  the  tendon  'Fig.  12  ,  The  tendon  is  thus  brought  beneath  the  blade 
of  the  knife  and  is  gradually  divided  by  rocking  movements,  while  an 
assistant  subjects  it  to  maximum  tension  by  corresponding  movement 
of  the  joint. 

Exarticulations  and  Amputations  of  the  Foot. — Exarticu- 
lations  of  the  Toes  in  the  Interphalangeal  or  Metatarso- 
phalangeal Joints. — Doi\ml  Opining  of  the  Joint,  tcith  the 
formation  of  a  Plantar  Teguraentary  Flap  by  Incision  from 
zvithin  Outirard. — The  operator  grasps  with  the  index- 
finger  and  the  thumb  of  the  left  hand  the  toe  flexed  at  the 
joint  of  separation,  and  the  joint  is  opened  by  a  transverse 
incision  upon  the  extensor  aspect,  somewhat  toward  the 
periphery  from  the  highest  prr)minence  of  the  joint.  Then 
the  lateral  ligaments  are  completely  severed  until  the 
joint  is  fully  opened.  Next  a  flap  is  formed  from  the 
plantar  tissues  by  an  incision  from  the  wound  outward. 
The  length  of  the  flap  will  be  governed  by  the  transverse 
extent  of  the  exposed  bone. 


AMPUTATIONS  ASU  ESUCLEATIOSS.  133 


Fig.  si. — Achilloteiiotomy :  the  tenotome  is  passed  beneath  the  relaxed 

tendon. 


AMPUTATIUXS  AM)  ENUCLEATIONS. 


135 


AMPUTATIONS  AXD  ENUCLEATIONS.  137 

^•l  larr/e  (lorstil and  d  short  phrninr  ttrf^imndtiry  jlap  may 
al.so  he  eniployeti  advantageuii.^ly  in  tlie  removal  of  toes ; 
as  well  as  tirolaiertd  Jiapfiof  equal  nize  ;  or  a  miff le  lateral 
tef/uinentart/  flap.  In  all  cases  the  flaps  are  carefully  out- 
lined with  the  knife,  se{xirate<l  from  the  suljjaeent  struct- 
ures, and  the  jnint  oju-ned  transversely  from  the  extensor 
aspect.  The  flaps  should  always  he  so  situated  that  their 
base  corresponds  with  the  joint-line  at  which  the  removal 
is  to  he  effe<'ted. 

In  making  an  oval  incision  the  knife  is  applied  u\K>n 
the  dorsal  asj)ect  somewhat  behind  the  line  of  the  joint. 
The  incision  then  runs  ])arallel  with  the  longitudinal 
axis  of  the  <ligit  in  tlie  middle  line  until  it  has  passed  the 
joint,  on  the  distal  side  of  which  it  deviates  toward  the 
right,  in  order  to  run  transversely  ujxm  the  flexor  aspect. 
From  here  it  is  c<  »ntinued  around  the  bone  until  it  reaches  the 
dorsal  aspect  ag*ain,  where  it  is  completeil  by  being  carried 
to  its  |x>int  of  origin.  The  joint  is  exposed  upon  its  dorsal 
aspect  by  dissecting  the  two  sides  of  the  oval,  and  opened 
transversely,  when  removal  may  be  effected  after  division 
of  the  plantar  tendons. 

Amputation  of  a  Toe  through  the  Metatarncd  Bone. — An 
oval  incision  is  made,  its  ajx^x  corresjx)nding  Avith  the 
point  at  which  the  metatarsal  bone  is  to  be  sawed  thr(jugh. 
The  incision  passes  longitudinally  over  the  metatarsus 
beyond  the  metatarsophalangeal  joint.  It  then  passes 
around  to  the  flexor  as}xct  and  back  again  on  the  opj)osite 
side,  to  return  to  its  point  of  origin.  The  nietatarsus  is 
dissected  free  in  the  course  of  the  lontjitudinal  inci^ion  and 
divided  with  the  phalangeal  saw  or  the  chain-saw.  The 
distal  extremity  is  grasjx'd  and  enucleated,  and  if  this  pro- 
cedure has  been  carried  out  to  the  transverse  incision  in 
the  flexor  fold  of  the  metatarsr)phalangeal  joint  the  sej^a- 
ration  will  have  been  completed. 

Amputation  of  (dl  Toes  through  the  Metatarsus. — A  large 
semicircular  plantar  and  a  >hort  dorsal  cutaneous  flap  are 
made.  The  ojxrator  >tands  at  the  periphery  of  the  ex- 
tremity, with  the  foot  held  in  maximum  dorsal   flexion, 


138 


OPERATIVE  SURGERY 


and  a  plantar  flap  is  cut  and  separated  from  the  metatarsal 
])ones.  The  dorsal  tegumentary  flap  is  then  outlined  and 
likewise  dissected  free.  The  metatarsal  bones  are  sur- 
rounded totally  by  a  circular  incision,  the  muscles  in  the 
interosseous  spaces  divided,  the  periosteum  of  each  bone 
individually  pushed  back  at  the  place  at  which  it  is  to  be 
sawed  through,  and  the  saw  finally  applied  from  the 
dorsum  of  the  foot  to  all  of  the  bones  simultaneously. 


*-*^2x 


Fig.  83. 


Ainputatiou   of  the  toes    tlirougli    the  metatarsus:   plantar 
iQusculo-tegumeutary  flap. 


The  plantar  flap  may  also  be  formed  by  cutting  out- 
ward from  the  wound  after  the  bones  have  been  salved 
through.  The  dorsalis  pedis  artery  and  the  digital  arte- 
ries will  require  ligation. 

Exarticulation  of  the  Great  Toe,  together  irifh  the  Jleta- 
tnrsnj  Bone. — An  oval  incision  is  made  Avith  a  prolonged 
apex.  The  dorsal  incision  begins  on  the  extensor  aspect 
over  the  metatarsophalangeal  joint  and  passes  in  the  longi- 
tudinal axis  of  the  metatarsus  to  the  head  of  this  bone, 
where  it  deviates  to  one  sidcj  then  surrounds  the  entire 


AMPUTATIONS  AND  ENUCLEATIONS.  139 

baseof  tlie  too,  and  thus  a^aiii  readies  tlic  dorsal  aspect  of 
the  toe,  joininti;  the  original  longitudinal  incision.  The 
inciision  at  all  points  is  made  down  to  the  bone.  Hooks  are 
introduced  on  either  side  of  the  longitudinal  incision,  and 
the  muscles  are  separated  from  the  metatarsus.  While 
the  toe  is  raised  the  metatarsal  boiu;  can  also  Ix;  freed  from 
the  muscles  npon  its  under  surface,  when  the  joint  between 
the  internal  cuneiform  bone  and  the  base  of  the  metatarsus 
can  be  opened  on  its  dorsal  aspect.  Linear  closure  of  the 
wound  is  finally  effected. 

Ex  articulation  of  the  Little  Toe,  together  with  the  Meta- 
tarsal Bone. — A  lateral  fla})  is  formed  according  to  the 
method  of  A\  alther.  The  oj^erator  grasps  the  abducted 
little  toe  and  a])plies  the  l)lade  of  the  knife  vertically  in 
the  interdigital  fold  between  this  and  the  adjacent  toe, 
when  the  soft  parts  of  the  interspace  are  divided,  by  saw- 
ing movements  of  the  knife  held  close  to  the  metatarsal 
bone  of  the  little  toe,  to  the  tarsus.  From  this  point,  with 
abduction  of  the  toe  and  the  metatarsus,  entrance  is  gained 
into  the  joint  between  the  fifth  metatarsus  and  the  cuboid 
bone,  w^hen  the  toe  is  bent  outward  at  the  joint  at  a  right 
angle  or  more.  The  operator  incises  the  tissues  around 
the  tuberosity  of  the  metatarsal  bone  close  to  the  bone, 
and  with  sawing-movements  detaches  the  soft  parts  from 
the  outer  side  of  the  metatarsal  bone  until  a  flap  has  been 
secured  of  sufficient  extent  to  cover  the  wound  made. 
The  flap  is  cut  transversely  from  the  wound  outward. 

The  little  toe  may  also  be  exarticulated  at  the  tarso- 
metatarsal joint  by  means  of  an  oval  incision,  the  apex  of 
Avhicli  is  made  upon  the  dorsum  of  the  foot,  as  in  removal 
of  the  great  toe.  The  apex  of  the  oval,  as  well  as  the 
longitudinal  incision,  may  also  be  placed  advantageously 
upon  the  lateral  border  of  the  toot. 

Removal  of  the  Foot  at  the  Tarsometatarsal  Joint.  Lis- 
franc's  Operation. — It  is  important  to  determine  the  situa- 
tion of  the  ends  of  the  line  of  the  tarsometatarsal  joint 
upon  the  inner  and  outer  borders  of  the  foot.  The  outer 
extremity  corresponds  with  a  point  just  behind  the  readily 


140  OPERATIVE  SURGERY. 

palpable  tuberosity  of  the  fifth  metatarsal  bone,  Avhile  the 
inner  extremity  is  about  a  thumb's  breadth  in  advance  of 
the  prominent  tuberosity  of  the  scaphoid  bone.  The  line 
of  the  tarsometatarsal  joint  is  not  a  directly  transverse 
line  between  the  two  points  named,  but  it  pursues  a  com- 
plex course.  From  the  fifth  metatarsal  bone  it  passes  for- 
ward at  an  angle  of  45°  ;  then  it  passes  inward  along  the 
base  of  the  fourth  metatarsal  bone.  The  next  joint,  be- 
tween the  external  cuneiform  and  the  base  of  the  meta- 
tarsal bone  of  the  middle  toe,  is  directly  transverse,  but 
projects  somewhat  forward.  The  articulation  between  the 
metatarsal  bone  of  the  second  toe  and  the  middle  cunei- 
form bone  is  also  transverse,  somewhat  behind  that  of  the 
third  metatarsal  bone  and  in  the  line  of  that  between  the 
fourth  metatarsal  and  the  cuboid  bone.  The  internal 
cuneiform  bone  projects  forward  (Figs.  84  and  85). 

Steps  of  the  Operation. — The  principle  of  the  operation 
consists  in  dorsal  opening  of  the  joint  and  the  formation 
of  a  musculotegumentary  flap  from  the  sole  by  an  incision 
from  within  the  wound  outward.  The  operator  stands  at 
the  periphery  of  the  foot  to  be  amputated,  which  he  grasps 
from  the  sole,  and  with  thumb  and  middle  finger  he  marks 
the  extremities  of  Lisfranc's  articular  line.  Then  an  in- 
cision through  skin  and  fascia  is  made  on  either  margin 
of  the  foot  do^vn  to  the  muscles  between  these  two  points 
— a  thumb's  breadth  in  advance  of  the  scaphoid  tuberosity 
on  the  inner  side  and  just  behind  the  tuberosity  of  the 
fifth  metatarsal  bone — on  the  outer  side  and  carried  for- 
ward beyond  the  heads  of  the  metatarsal  bones.  An 
incision  convex  anteriorly  over  the  dorsum  of  the  foot 
then  unites  the  posterior  extremities  of  these  lateral  in- 
cisions. After  division  of  the  skin  and  the  subcutaneous 
connective  tissue  the  dorsal  flap  is  somewhat  retracted. 
At  the  point  of  retraction  the  tendons  and  muscles  of  the 
dorsum  of  the  foot  are  divided  accurately  in  the  direction 
of  the  cutaneous  incision.  There  are  thus  exposed  upon 
the  dorsum  of  the  foot  the  bones  and  the  ligaments  of  the 
joints  throughout  a  small  extent.    The  delicate  dorsal  cap- 


AMPUTATToy.S  AM)  EyUCLKAllONS. 


11 


Fig.  84. — Lisfranc's  articular  line :  exposed  articular  line  upon  the  foot. 


Fig.  85. — Course  of  Lisfranc's  articular  line  Rafter  van  Walsen) :  0«, 
cuboid  bone;  A'l,  K2.  A'3,  external,  middle,  and  internal  cuneiform  bones. 
/, //,  ///,  IV,  r,  articular  surfaces  of  the  corresponding  metatarsal  bones. 
I,  metatarsal  bone  of  the  great  toe. 


AMPI'TATIOSS  AM)   KMX'LKATlOSS.  143 

EXAKTICULATIoN   OF   THE   FOOT   BY   LiSFRANC'S   METHOD. 


Fig.  86. — The  foot  is  flexed  on  the  sole  at  Lisfranc's  joint :  formation 
of  the  plantar  musculotegumeutary  flap  by  incision  from  within  outward. 


^^?5»!>i'^.. 


P^G.  87. — Stump  left  by  Lisfranc's  operation. 


AMrUTATIONS  AM)  KMJCLEATIONS.  145 

sulcs  of  tho  joints  arc  now  slit  open,  with  the  foothold  in 
slic:ht  plantar  flexion.  The  opening;  of  the  joints  is  always 
Ix'gnn  at  the  external  border,  at  the  artienlation  hetMcen 
the  fifth  metatarsal  bone  and  the  lateral  facet  of  the 
enboid  bone,  as  this  can  always  be  readily  found  if  the 
knife  is  introduced  behind  the  prominence  of  the  fifth 
metatarsal  bone  and  the  incision  is  directed  obliquely  for- 
ward and  inward.  According  to  Bergmann,  tins  joint 
coincides  with  the  direction  of  a  line  passing  from  the 
tuberosity  of  the  fifth  metatarsal  bone  to  the  head  of  the 
first  metatarsal  bone.  After  this  first  joint  has  been 
opened  the  course  of  the  remainder  of  the  complex  articu- 
lar line  can  be  made  out  from  the  landmarks  mentioned. 
The  operator  therefore  directs  his  knife  more  toward  the 
middle  line  of  the  foot  and  opens  the  almost  transverse 
joint  between  the  cuboid  bone  and  the  fourth  metatarsal. 
The  next  also  transverse  joint  is  situated  somewhat 
further  forward.  The  transverse  line  of  the  joint  between 
the  second  metatarsal  bone  and  the  middle  cuneiform  bone 
is  readily  found,  corresponding  with  a  prolongation  inward 
of  the  articular  line  of  the  fourth  metatarsal  bone  (Fig.  85). 
The  joint  between  the  first  metatarsal  bone  and  the  in- 
ternal cuneiform  bone  also  is  situated  further  forward. 
The  articular  surfaces  must  be  exposed  by  short  incisions 
directed  against  the  bone.  The  longitudinal  articular 
surfaces  are  likewise  exposed,  and  with  increasing  plantar 
flexion  of  the  foot  the  short  ligaments  that  unite  the 
bones  in  the  depth,  as  well  as  the  ligaments  of  the  sole, 
in  so  far  as  these  fall  within  the  range  of  the  incision, 
are  divided,  until  the  whole  series  of  joints  is  opened 
to  a  maximum  degree.  It  is  now  still  necessary  to  form 
a  plantar  flap.  This  must  be  so  constituted  as  to  include 
at  its  base  the  soft  parts  of  the  entire  sole.  The  substance 
of  the  flap  gradually  diminishes  in  amount  toward  its 
periphery,  so  that  at  its  extremity  it  consists  only  of  skin 
and  subcutaneous  connective  and  fatty  tissue,  and  it  is 
thus  readily  united  with  the  delicate  skin  of  the  dorsum 
of  the  foot  (Fig.  87).     With  a  long  knife  an  incision  is 

10 


146  OPERATIVE  SURGERY. 

made  horizontally  through  the  sole  around  the  sesamoid 
bones  at  the  head  of  the  metatarsal  bone  of  the  great  toe, 
the  knife  being  brought  out  of  the  wound  transversely 
beyond  the  head  of  the  metatarsal  bone  (Fig.  88).     The 


Fig.  88. — Form  and  extent  of  the  plantar  flap  in  Lisfranc's  operation. 

dorsalis  pedis  and  the  internal  plantar  artery  are  to  be 
ligated  in  the  stump. 

The  stump  left  by  Lisfranc's  operation  yields  good 
functional  results.  The  flap  is  firm  and  well  padded,  and 
the  cicatrix  lies  upon  the  dorsal  aspect  quite  out  of  the 
area  of  the  walking-surface.  The  extensors  of  the  ankle- 
joint  (tibialis  anticus,  peroneus  brevis),  important  as  antag- 
onists of  the  triceps,  are  maintained  in  their  attachments. 

Intertarsal  Amputation. — The  joint  between  the  anterior 
surface  of  the  scaphoid  bone  and  the  three  cuneiform 
bones  is  opened,  and  the  cuboid  bone  is  sawed  through 
transversely  in  the  lateral  prolongation  of  the  joint  named. 
The  cutaneous  incisions  are  the  same  as  in  Lisfranc's 
operation.  The  joint  in  front  of  the  scaphoid  bone,  recog- 
nizable by  its  articular  surface  with  three  facets,  is  opened 
from  the  dorsum  of  the  foot  and  made  to  gape  widely. 
The  periosteum  upon  the  dorsal  surface  of  the  cuboid 
bone  is  incised  transversely  and  the  bone  divided  accord- 
ingly with  the  phalangeal  saw.  The  bone  is  held  in 
plantar  flexion  and  the  jilantar  flap  is  made  as  in  Lis- 
franc's operation. 


AMPUTATIOXS  ASD  EXUCLEATIOyS. 


U' 


Fig.  89.— Chopart's  articnlar  line:  T.  head  of  the  astragalus:  X, 
scaphoid  bone :  Cit,  os  calcis;  Cu,  cuboid  bone.  The  calcaneoscaphoid 
interosseous  ligament  is  exposed  by  dissection. 


AMPUTATIONS  AND  ENUCLEATIONS.  149 

Intertarsal  Exarticulation.  Chopart's  Operation. — The 
a.stra<»al()S('aj)hni(l  articulation  upon  the  one  liainl  and  the 
eal('an('o<'ul)oi(l  articuhition  upon  the  other  liand  constitute 
approximately  a  transverse  line  in  ^vhich  the  foot  may  be 
(livi(hMl  within  the  tarsus.  The  extremity  of  tliis  articu- 
lar line  upon  the  inner  l)order  of  the  foot  lies  just  hehind 
the  tuberosity  of  the  scaphoid  bone  ;  while  upon  the  outer 
side  the  calcaneocuboid  iirticulation  will  be  entered  if  the 
incision  is  made  a  thumb's  breadth  behind  the  tuberosity 
of  the  fifth  metatarsal  bone.  Chopart's  joint  is  not  repre- 
sented by  a  directly  transverse  line  between  these  two 
points,  but  is  curved  somewhat  as  follows  :  the  head  of 
the  astragalus  is  directed  with  its  convexity  forward, 
while  the  anterior  articular  surface  of  the  os  calcis  is  on 
the  contrary  excavated  (Fig.  89).  The  calcaneoscaphoid 
interosseous  ligament  maintains  the  bones  in  apposition 
after  division  of  the  articular  capsule. 

The  operator  occupies  the  same  position  as  in  Lisfranc's 
operation  and  lateral  incisions  are  made  along  the  borders 
of  the  foot  outlining  the  plantar  flap,  the  posterior  ex- 
tremities of  which  are  united  by  an  incision  passing  trans- 
versely over  the  dorsum  of  the  foot.  The  joint  between 
the  head  of  the  astragalus  and  the  scaphoid  bone-  is 
always  opened  first.  It  is  not  to  be  mistaken,  as  its  situ- 
ation is  indicated  by  the  prominent  head  of  the  astragalus, 
in  advance  of  which  the  incision  is  made,  as  ^yell  as  by 
the  tuberosity  of  the  scaphoid  bone,  behind  which  the 
incision  passes.  In  order  to  divide  the  calcaneoscaphoid 
interosseous  ligament  and  to  open  the  calcaneocuboid 
articulation,  the  point  of  the  knife  is  inserted  in  the  outer 
extremity  of  the  already  opened  astragaloscaphoid  articu- 
lation, and  the  blade  is  directed  toward  the  middle  of  the 
small  toe,  and  the  tensely  stretched  ligament  is  divided 
with  a  slight  degree  of  pressure.  The  foot  is  flexed  in 
the  line  of  the  o])en  joint;  the  ligaments  of  the  sole  of 
the  foot  are  divided  in  the  line  of  the  incision,  and  the 
plantar  flap  is  made  similar  to  that  in  Lisfranc's  opera- 
tion, though  correspondingly  smaller,  a  finger's  breadth 


150  OPERATIVE  SURGERY. 

behind  the  head  of  the  metatarsal  bone.  In  the  stamp 
the  dorsalis  pedis  and  the  internal  and  external  plantar 
arteries  will  require  ligation. 

If  the  directions  given  be  not  strictly  followed,  it  is 
possible  that  instead  of  entering  the  astragalocuboid  joint 
the  operator  may  enter  that  between  the  anterior  surface 
of  the  scaphoid  and  the  three  cuneiform  bones.  The 
retention  of  the  scaphoid  bone  would  scarcely  be  a  dis- 
advantage, inasmuch   as   the   posterior   tibial    muscle   is 


Fig.  90. — Subastragaloid  enucleation  of  the  foot :  tegumentary 

incision. 

attached  to  it.  Jobert  has  recommended  this  method  of 
prescaphoid  enucleation  as  a  regular  procedure. 

The  stump  left  by  Chopart's  exarticulation  has  a  ten- 
dency to  fix  itself  in  a  position  of  club-foot.  This  defect, 
it  is  thought,  can  be  overcome  by  certain  modifications, 
such  as  Jobert's  prescaphoid  exarticulatiou,  as  well  as 
intertarsal  amputation,  inasmuch  as  the  attachment  of 
the  tibialis  anticus  muscle  to  the  scaphoid  bone  is  pre- 
served and  dorsal  flexion  is  rendered  possible. 

Subastragaloid  Enucleation  of  the  Foot. — (Textor,  Gun- 


AMPUTATIOSS  AND  ENUCLEATIONS. 


151 


ther,  Malgaigne.) — It'af'tcr  ciiuclcatioii  of  the  foot  at  Cho- 
l)art's  joint  tlu'  calcaiicimi  is  additionally  removed,  tlie  as- 
tragidiis  alone  of  the  tarsus  is  lei't  in  eonneetion  with  the 
leg.  This  form  of  enucleation  of  the  foot,  which  is  known 
as  exarticulatio pedis  sub  talo,  was  performed  and  introduced 


Fig.  91. — Subastrajjaloid  enucleation  of  the  foot :  dissection  of  the 
flap  from  the  inner  surface  of  the  calcaneuui :  T,  astragalus ;  C,  calca- 
neum. 

by  Malo:aigne  as  a  regular  procedure.  In  the  original  ope- 
ration the  incisions  were  like  those  in  Syme's  operation, 
altliough  the  dorsal  tegumentary  flap  extended  beyond 
Chopart's  joint.  The  foot  was  removed  at  this  joint,  and 
then  the  os  calcis  was  extirpated.  The  best  incision  for 
amputation  of  the  foot  at   the    calcaneo-astragaloid    and 


152 


OPERATIVE  SURGERY. 


astragaloscaphoid  joints  is  that  of  Giinther,  who  em- 
ploys an  internal  flap  extending  to  the  sole  to  cover  the 
wound. 

The  incision  (Fig.  90)  begins  over  the  tuberosity  of  the 
OS  calcis  in  the  middle  line  of  the  heel,  passes  thence  in 


Fig.  92. — Stumji  following  Malgaigne's  operation. 

an  arched  direction  below  the  external  malleolus,  and 
turns  at  the  level  of  Chopart's  joint  toAvard  the  median 
line,  to  continue  transversely  across  the  dorsum  of  the 
foot  to  its  inner  border,  whence  it  courses  over  the  sole 
of  the  foot  to  the  middle  line.  From  this  point  the 
incision   is    continued   backward    at   an    oblique    angle, 


AMPIJTATIOXS  AM)  ENUCLEATIONS. 


153 


thn)iiii:li  the  skin  of  tlie  .sole,  to  reach  the  point  of  origin 
over  the  tuherosity  of  the  (js  ealeis.  The  incision  every- 
w  luTe  reaches  down  to  the  bone. 

The  articuhition  between  the  liead  of  the  astragahis 
and  the  scaphoid  bone  is  first  opened,  and  then  the  eon- 
n(H'tions  between  the  astrac^ahis  and  the  os  calcis  are 
divided  in  the  tarsal  sinus.  If  the  under  surface  of  tlie 
astragahis   is  thus   freecl,  the  flap   outlined   is  separated 


Fig.  93. — Enucleation  at  the  knee-joint:   outline  of  the  flaps. 

close  to  the  bone  from  the  inner  surface  of  the  os  ealeis, 
while  the  foot  is  rotated  outward  upon  its  longitudinal 
axis  (Fig.  91).  In  opening  the  joint  between  the  head  of 
the  astragalus  and  the  concavity  of  the  scaphoid  bone  the 
calcaneocuboid  articulation  should  not  be  included  within 
the  range  of  the  incision.  The  articulation  between  the 
trochlear  surface  of  the  astragalus  and  the  bones  of  the 
leg  should  also  be  protected. 

Exarticulation  of  the  Leg  at  the  Knee-joint. — An  anterior 


154  OPERATIVE  SURGERY. 

tegumentary  flap  is  made  upon  the  extensor  aspect  of  the 
leg,  and  the  joint  opened  from  this  surface.  A  short  mus- 
culotegumentarv  flap  is  formed  upon  the  flexor  aspect  by 
an  incision  from  the  wound  outward.  The  teo-umentarv 
flap  has  a  broad  h'ASQ,  and  its  lower  extremity  extends 
below  the  tuberosity  of  the  tibia. 

The  operator  stands  at  the  periphery  of  the  member. 
The  anterior  flap  is  outlined  by  incision  with  the  knife. 
The  incisions,  passing  vertically  downward  from  the  most 
prominent  points  of  the  external  and  internal  condyles  of 
the  femur,  extend  three  or  four  fingers'  breadth  below  the 
tuberosity  of  the  tibia,  at  which  level  they  are  united  by 
a  transverse  incision.  The  corners  of  the  flap  thus  formed 
are  rounded.  The  flap  is  now  dissected  from  the  subja- 
cent structures  to  the  level  of  the  patellar  ligament.  \Yith 
the  extremity  flexed  at  the  knee  the  operator  grasps  the 
leg  with  his  left  hand,  divides  the  patellar  ligament  with 
a  single  transverse  incision,  and  enters  the  joint.  The 
lateral  ligaments  and  the  crucial  ligaments  of  the  knee- 
joint  are  next  divided,  so  that  the  leg  is  attached  to  the 
thigh  by  only  the  posterior  wall  of  the  capsule  of  the  joint 
and  the  soft  parts  of  the  popliteal  space.  A  long  knife  is 
introduced  into  the  wound  behind  the  tibia,  and  its  edge 
is  directed  toward  the  periphery  of  the  extremity,  avoid- 
ing the  head  of  the  fibula,  a  short  musculotegumentary 
flap  being  formed  from  the  soft  parts  of  the  flexor  aspect 
by  incision  from  within  outward.  By  these  means  the 
popliteal  artery  is  not  divided  till  the  last  stage  of  the 
operation.  The  patella  remains  connected  Avith  the  ante- 
rior flap. 

Pollosson  recommends  that  the  operation  be  so  performed  that  the  cap- 
sule of  the  joint  is  opened  close  to  the  tibia  in  order  that  after  separation 
of  this  bone  the  capsule  may  be  again  closed  by  suture.  In  this  way  a 
cavity  is  formed  above  the  stump.  Recovery  is  said  to  take  place 
promptly  and  the  stump  is  believed  to  gain  in  usefulness. 

Amputation  of  the  Thigh. — Among  methods  of  ampu- 
tation of  the  thigh  that  may  be  employed  advantageously 
are :  the  circular  incision  in  two  steps,  with  the  formation 


AMPl'TATIONS  AND  ENUCLEATIONS.  155 

of  a  ciilV;  and  ol'  ilap-incisions  an  ant(  ri<»i-  and  a  posterior 
niiiscnlott'iiuniciitarv  flap  of  (Mpial  si/c,  or  a  lon^-  anterior 
and  a  short  posterior  niusenloteguincntary  Hap. 

Anqjutiitioii  of  the  Thi(//i  bi/  Matnn  of  a  Circuhir  Inci- 
sion in  Two  tStrps. — The  pelvis  of  the  subject  is  brought 
to  the  edge  of  the  tal)h'.  In  amputating  tli(^  riglit  thigli 
the  operator  stands  upon  tlie  outer  si(U' ;  and  in  amputa- 
tion of  the  left  thigh,  upon  the  inner  side  of  the  extremity, 
Avhieh  is  lieUl  securely  in  a  horizontal  position.  At  a  suf- 
ficient distance  toward  the  periphery  from  the  point  at 
which  the  bone  is  to  be  divided  a  circular  incision  is  made 
through  the  skin  down  to  the  fascia,  and  a  cuff  turned 
back.  At  the  point  of  reflection  of  this  cuff  the  muscles 
are  divided  down  to  the  bone  in  four  steps  A\ith  vigorous 
strokes  of  a  long  knife.  The  bone  is  divided  with  the 
saw  at  a  point  somewhat  proximal  to  the  incisions  through 
the  muscles.  For  this  purpose  the  operator  with  the  index- 
finger  and  thumb  of  his  left  hand  pushes  back  the  mus- 
cles upon  the  bone  and  divides  the  latter  somewhat  fur- 
ther from  the  periphery.  The  periosteum  in  the  path  of 
the  incision  is  detached  from  the  bone  by  means  of  a  raspa- 
tory in  the  area  to  be  saw'ed  through,  and  the  bone  is  di- 
vided with  a  saw,  while  the  muscles  are  retracted  by  means 
of  either  tenacula  or  a  divided  bandage.  In  the  center  of 
the  stump  (Plate  9)  may  be  seen  the  transverse  section  of 
the  femur,  around  which  the  muscles  are  so  grouped  that 
upon  the  anterior  surface  lies  the  quadriceps  femoris, 
while  u})on  the  posterior  surface  lie  the  flexors.  To  the 
inner  side  the  group  of  adductors  lie  wedged  between  the 
flexors  and  the  extensors.  The  depression  between  the 
adductors  and  the  extensors  is  covered  by  the  sartorius 
muscle.  In  the  space  enclosed  by  these  muscles,  which  is 
triangular  in  cross-section,  are  to  be  found  the  femoral 
artery  and  vein,  as  well  as  the  saphenous  nerve.  Between 
the  flexors  is  the  sciatic  nerve,  always  accompanied  by 
vessels.  In"  the  connective-tissue  interstices  of  the  mus- 
cles are  small  arterial  vessels  divided  transversely  or  visi- 
ble in  longitudinal  sections.     After  control  of  hemorrhage 


156  OPERATIVE  SURGERY. 

Plate  9. — Transverse  Incision  through  the  Left  Thigh  at  its 

Middle  Third. 

Q,  quadriceps  femoris  muscle  ;  S,  sartorius  ;  Ad,  group  of  adductors  ;  F, 
group  of  flexors;  G,  gracilis;  A.C.,  femoral  arterj' in  a  common  sheath 
with  the  profunda  artery,  the  femoral  veins,  and  the  saphenous  nerve; 
Xi,  sciatic  nerve. 

the  muscles  are  to  be  so  united  bv  buried  sutures  that  the 


Fig.  94. — Diagrammatic  representation  of  Gritty's  operation. 

formation  of  cavities  and  dead  spaces  is  avoided.     The 
skin  is  united  by  deep  and  superficial  sutures. 


Fig.  95. — Diagrammatic  representation  of  Ssabanajeffs  operation. 
Flap -amputations  of  the  Thigh. — Anterior  and  Posterior 


AMPUTA TIOXS  . I  \n   IJNUCLKA  TIOXS. 


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AMrCTATlOXS   AM)   KMJCLEATIOSS.  Kil 

MiLSCulotegumcntary  Fl<(j)s. — The  H:ij)s  arc  semicircular 
and  well  roiuidcd.  15(>tli  Haps  incft  upon  the  lateral  as- 
pects of  the  thigh  in  such  a  manner  that  the  base  of  ca(;h 
corresponds  to  half  the  circumference  of  the  part.  The 
operator  marks  the  outlines  of  the  flaps  by  incisions  pass- 
ins:  throusch  skin,  fatty  connective  tissue,  and  the  fascia  lata, 
down  to  the  muscles.  Both  Haps  may  be  formed  l)y  trans- 
fixion or  by  incision  froQi  the  periphery  to  the  base.  The 
flaps  are  reflected  at  their  bases,  and  the  muscles  attached 
to  the  bone  are  divided  by  a  circular  incision.  The  bone 
is  sawed  throuo^h  in  the  usual  manner  and  the  wound  is 
closed  by  suture. 

Osteoplastic  Supracondylar  Amputation  of  the  Thigh  by 
the  Method  of  Gritty. — Gritty  has  ingeniously  applied  the 
osteoplastic  principle  of  PirogoflPs  operation  to  amputa- 
tions at  the  knee-joint,  the  freshened  surface  of  the  patella 
being  approximated  to  the  sawed  surface  of  the  femur,  and 
union  taking  place. 

3Iocle  of  Procedure. — An  anterior  flap  is  made  as  for 
exarticulation  of  the  leg.  This  is  dissected  free  to  the 
level  of  the  patellar  ligament  and  the  joint  is  opened 
transversely  in  this  situation.  At  the  same  time  the 
lateral  attachments  of  the  capsule  attached  to  the  con- 
dyles of  the  femur  are  divided  so  that  the  flap,  with  the 
patella  contained  within  it,  can  be  reflected.  The  patella 
is  surrounded  by  an  incision  on  the  synovial  surface  of 
the  flap,  and  freshened  by  removal  of  its  cartilaginous 
articular  surface  with  the  phalangeal  saw  (Fig.  96).  The 
flap  is  now  somewhat  retracted,  so  that  the  supracondylar 
portion  of  the  femur  is  exposed.  An  incision  is  made 
around  the  bone  in  this  situation,  the  bone  is  sawed 
through,  and  a  short  tegumentary  flap  is  formed  from 
the  soft  parts  of  the  popliteal  space  by  an  incision  from 
within  outward.  The  patella  is  approximated  to  the 
sawed  surface  of  the  femur  and  fixed  in  this  situation 
by  bone-sutures  or  percutaneous  pegs.  The  stump  (Fig. 
98)  yields  a  functionally  good  result  by  reason  of  closure 


11 


162 


OPERA  TIVE  S  UR  GER  Y. 


of  the  medullary  cavity  of  the  femur  Avith  l^one  and  the 
favorable  situation  of  the  cicatrix. 

Ssabanajeif  has  modified  the  method  of  amputating  the 
leg  at  the  knee  by  bringing  a  segment  of  the  tibia  in  ap- 
proximation with  the  sawed  extremity  of  the  femur,  and 
the  results  are  said  to  be  superior  to  those  of  Gritty 's 
operation.  An  incision  is  made  through  the  skin  on  the 
anterior  aspect  of  the  leg,  as  in  Gritty's  operation.     A 


Fig.  99. — The  •wound  made  in  SsabanajeflTs  operation :  T,  sawed  seg- 
ment of  the  tibia  for  approximation  to  the  femur ;  F,  sawed  surface  of 
the  femur. 


short  flap  is  outlined  in  the  popliteal  space  with  an  arched 
incision  and  dis.sected  free,  the  knee-joint  being  opened 
from  the  popliteal  space.  The  leg  is  so  bent  at  the  knee- 
joint  that  the  .surface  of  the  tibia  is  brought  in  apposition 
with  the  anterior  aspect  of  the  thigh.  From  the  articular 
surface  a  transverse  plate  of  bone  is  removed  from  the 
upper  extremity  of  the  tibia  as  low  down  as  its  tuberosity, 
and  this  remains  connected  with  the  anterior  flap.  The 
thigh  is  further  divided  transverselv  throuo-h  its  condvles. 


AMPUTATIOXS  AXD  EXVCLEATIOyS.  163 

The  sup|x>rting  surface  of  the  stump  is  thus  formed  by 
the  tuberosity  of  the  tibia,  and  clinical  rejKnis  are  in 
accord  in  the  statement  that  it  s^^rves  this  puqx)se  ad- 
mirably (Figs.  95  and  W). 

Exarticulation  of  the  Pemur  at  the  Hip-joint  by  the 
Method  of  Esmarch. — The  CMmbinatiun  of  circular  ampu- 
tatiuii  of  the  thigh  with  a  luugitudinal  incision  (Esmarch) 
permits  the  removal  of  Jthe  femur  with  a  minimum  loss 
of  blood.  The  pelvis  of  the  subject  extends  beyond  the 
border  of  the  table  and  the  operator  stands  as  in  the  per- 
formance of  amputation.  After  the  application  of  an 
Esmarch  bandage  as  close  to  the  tnmk  as  possible  a  cir- 
cular incision  is  made  through  the  skin  down  to  the  muscles 
in  the  upper  third  of  the  thigh.  At  the  point  of  retraction 
of  the  skin  the  muscles  are  divide-d  typically  in  a  circular 
manner  down  to  the  bone.  The  periosteum  is  likewise 
incised  and  the  bone  is  sawed  through.  The  next  step 
consists  in  thorough  ligation  of  the  vessels  in  the  trans- 
verse incision.  After  the  lumen  of  all  the  visible  vessels 
is  closed  by  ligature  the  bandage  is  removed.  Then  a 
longitudinal  incision  is  made  upon  the  lateral  aspect  of 
the  thigh,  |xissing  over  the  great  trochanter,  dividing  the 
soft  parts  down  to  the  bone,  and  extending  to  the  level  of 
the  wound  (Fig.  100).  Hooks  are  introduced  into  the 
margins  of  the  incision  and  the  bone  is  freed  fix)m  its 
attachments.  When  the  separation  has  been  effected 
throughout  a  sufficient  extent,  the  operator  grasps  the 
bone  with  his  left  hand,  opens  the  joint,  dislocates  the 
head  of  the  femiu*,  and  severs  the  round  ligament,  Avhen 
the  central  portion  of  the  femur  can  be  removed.  The 
whole  operation  can  be  performe<l  without  noteworthy 
loss  of  bl<x»d. 

Exarticulation  at  the  Hip-joint,  with  the  Formation  of  an 
Anterior  and  a  Posterior  Musculotegnmentary  Plap  by 
Transfixion. — The  j>erformance  of  enucleation,  witli  the 
formation  of  two  larr/e  musculotegumentary  jlaps  by  trans- 
tixion,  renders  possible  rapidity  of  exarticulation,  although 
the  control  of  hemorrhage  is  difficult.     The  mode  of  pro- 


164 


OPERATIVE  SURGERY. 


cedure  occupied  a  prominent  position  in  surgery  at  a  time 
when  rapidity  of  operation,  ^Yhich  had  to  be  undertaken 
without    anesthesia,   was   a   primary   consideration.     At 


Fig.  100.— Exarticulation  at  the  hip-joint: 
combination  of  circular  incision  and  external 
longitudinal  incision. 


present,  however,  it  is  considered  more  important  in  an 
operation  to  reduce  the  loss  of  blood  to  a  minimum.  Thus, 
in  exarticulation  of  the  hip  by  the  method  of  Verneuil  the 


AMPUTATIONS  ASn  ESVCLEATI02iS. 


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Fig.  101.— Enucleations  of  the  finders:  enucleation  of  the  middle 
finger  at  the  iiiterphalangeal  joint :  opening  of  the  joint  on  its  dorsal 
aspect.  Formation  of  a  palmar  flap  by  incision  from  within  outward. 
Upon  the  thumb  :  line  of  incision  for  removal  of  the  thumb  at  the 
carpometacarpal  joint  by  means  of  an  oval  incision.  Upon  the  index- 
finger  :  flap-incisions. 


AMPUTATIONS  AND  ENUCLEATTONS.  1  G7 

muscles  are  divided,  step  by  step,  with  iiii  ordinary  scalpel, 
divided  vessels  being  inniiediately  <!;rasped,  and  lar<rer 
vessels  l)eing  secured  in  advance  of  division  by  two  bga- 
tures.  The  operation  under  consideration,  although  it 
requires  a  longer  time,  is  performed  with  the  utmost  care 
and  with  least  possible  loss  of  blood.  This  method  of 
procedure,  in  which  the  separation  of  tlie  tissues  is  effected 
according  to  tlie  principles  observed  in  the  enucleation  of 
tumors,  is  therefore  designated  extirpation. 

Exartimlation  at  the  Hip-joint  by  Mcam  of  Fhtp- 
transfixion. — Two  tongue-shaped  flaps  are  made  that  reach 
to  the  junction  of  the  midille  and  upper  thirds  of  the. 
fenuu',  the  knife  being  always  introduced  from  right 
toward  left.  If,  for  instance,  tlic  left  lower  extremity  is 
to  be  removed,  the  knife  is  introduced  horizontally  upon 
the  outer  side  of  the  hip  at  a  point  midway  between  the 
anterior  iliac  spine  and  the  apex  of  the  greater  trochanter, 
and  passed  through  the  soft  parts  of  the  thigh  just  in  front 
of  the  capsule  of  the  hip-joint,  and  brought  out  in  the 
genitocrural.  fold.  The  flap  is  cut  of  suitable  length  and 
folded  back.  Tlie  operator  grasps  the  thigh  with  his  left 
hand,  places  the;  hip-joint  in  maximimi  extension,  and 
opens  the  joint  through  an  arched  incision  that  penetrates 
the  anterior  wall  of  its  capsule.  The  head  of  the  fenuu' 
is  forced  out  of  the  wound  and  the  round  ligament  is 
severed.  The  posterior  wall  of  the  capsule  is  next 
divided  from  the  interior  of  the  joint ;  the  greater  tro- 
chanter is  exposed  by  a  few  incisions,  and  a  musculoteg- 
umentary  flap  is  formed  from  the  soft  parts  of  the  flexor 
aspect  by  an  incision  from  within  outward.  Care  should 
be  taken  that  the  flaps  are  not  too  small,  and  it  is  further 
important  in  making  the  incision  from  within  outward 
that  the  muscles  are  properly  divided,  so  as  not  to  extend 
beyond  the  margins  of  the  flap. 

Amputations  and  Bxarticulations  of  the  Upper 
Extremity. — Exarticulation  of  the  Fingers  at  the 
Interphalangeal  Joints  and  at  the  Metacarpophalangeal 
Joints. — In  the  enucleation  of  part  of  a  finger  the  inter- 


168  OPERATIVE  SURGERY. 

phalangeal  joint  is  opened  transversely  upon  its  dorsal 
aspect  and  a  flap  is  formed  from  the  skin  upon  the  flexor 
aspect  by  incision  from  within  outward.  The  operator 
grasps  with  the  thumb  and  index-finger  of  his  left  hand 
the  finger  flexed  at  the  joint  at  which  removal  is  to  be 
eflected.     A  transverse  incision  upon  the  dorsal  aspect  on 


Fig.  102.— Enucleations  of  the  fingers.  On  the  index-finger  :  line  of 
oval  incision  for  enucleation  at  the  metacarpophalangeal  joint ;  cuta- 
neous incision  for  resection  of  the  middle  phalanx.  On  the  thumb  :  for 
the  same  operation  the  skin  is  already  freed  and  the  joint  has  been 
opened  on  its  dorsal  aspect.  On  the  middle  finger :  cutaneous  mcision 
for  resection  of  the  first  interphalangeal  joint. 

the  peripheral  side  of  the  most  marked  prominence  of  the 
joint  opens  this.  The  lateral  ligaments  of  the  capsule  are 
divided,  and,  with  the  joint  opened  to  its  maximum  ex- 
tent, a  short  tegumentarv  flap  is  formed  upon  the  palmar 
aspect  l)v  incision  from  within  outward  (Fig.  101).  The 
length  of  the  flap  will  be  governed  by  the  size  of  the 
wound  to  be  covered. 


AMPUTATIONS  AND  ENUCLEATIONS. 


169 


AMPUTATIONS  AND  ENUCLEATIONS.  171 


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AMPUTATIONS  AND  ENIJCLEATTONS.  173 

A  large  dorsal  and  a.  sJiort  plantar  tegmnentary  flap  may 
also  be  made  advantageously,  as  well  as  two  lateral  flaps 
of  equal  size  or  a,  .vngle  lateral  tegumentary  flap. 

The  outline  of  the  Hap  is  always  first  carefully  made 
with  a  knife ;  the  flap  is  then  dissected  free  from  the  sub- 
jacent tissues,  and  the  joint  is  opened  from  the  extensor 
aspect.  The  flaps  should  be  so  situated  that  their  bases 
correspond  with  the  line  of  the  articulation  at  which  re- 
moval is  to  be  effected. 

In  making  an  ovalincision  the  operator  applies  the  knife 
upon  the  extensor  aspect  somewhat  to  the  proximal  side  of 
the  line  of  the  articulation  and  divides  the  tissues  in  the 
middle  line  parallel  with  the  longitudinal  direction  of  the 
finger  until  the  joint  has  been  passed.  On  the  distal  side 
of  the  joint  the  incision  turns  toward  the  right  to  run 
transversely  through  the  flexor  fold  of  the  joint  and 
it  returns  upon  the  opposite  side  of  the  finger,  to  termi- 
nate at  its  point  of  origin  (Fig.  102).  By  detaching  the 
tissues  on  either  side  of  the  oval  from  the  subjacent  struct- 
ures the  joint  is  exposed  upon  its  extensor  aspect  and  the 
removal  of  the  finger  can  be  readily  effected.  Hemor- 
rhage will  be  controlled  by  ligation  of  the  digital  arteries, 
which  run  on  either  side  near  the  palmar  surface.  The 
wound  left  after  oval  incision  is  closed  in  a  linear 
direction. 

For  enucleation  of  the  thumb  at  the  carpometacarpal 
joint  an  oval  incision  is  best  suited.  The  apex  of  the 
oval  is  situated  upon  the  extensor  aspect  of  the  thumb  at 
a  point  corresponding  to  that  at  which  removal  is  to  be 
effected.  At  the  metacarpophalangeal  joint  the  incision 
deviates  toward  the  flexor  aspect,  passing  transversely 
through  the  flexor  fold  of  this  joint  and  ascends  upon  the 
opposite  side  of  the  finger  to  join  the  longitudinal  incision 
at  an  acute  angle  (Fig.  101).  The  incisions  extend 
throughout  down  to  the  bone,  from  which  the  soft  parts 
of  the  thenar  eminence  are  carefully  dissected.  After  the 
metacarpal  bone  has  been  freed  the  joint  between  the 
trapezium  and  the  base  of  the  metacarpal   bone  of  the 


174  OPERATIVE  SURGERY. 

thumb  is  opened  from  the  dorsal  aspect  and  the  finger  is 
separated. 

Exarticulation  of  the  little  finger  togetlier  icith  its  meta- 
carpal hone  by  means  of  a  flap  from  the  integument  of 
the  ulnar  border  by  the  method  of  ^^'alther.  The  fourth 
and  fifth  fingers  are  extended  and  held  in  a  position  of 
maximum  abduction.  AVith  the  dorsum  of  the  hand 
directed  toward  the  operator,  the  blade  of  the  knife  is 
introduced  at  the  middle  of  the  commissure  between  the 
fourth  and  fifth  fingers  and  passed  with  sawing-move- 
ments  through  the  soft  parts  of  the  interosseous  space 
between  the  fourth  and  fifth  metacarpal  bones  to  the  root 
of  the  hand.  With  the  point  of  the  knife,  now  directed 
toward  the  radial  border,  the  ligaments  uniting  the  bases 
of  the  two  metacarpal  bones  are  first  divided,  while  the 
little  finger  is  held  in  a  position  of  marked  abduction, 
after  which,  by  traction  in  the  direction  of  abduction,  the 
finger  can  be  bent  outward  in  the  joint  between  the 
unciform  bone  and  the  metacarpus.  The  operator  noAv 
surrounds  the  base  of  the  metacarpal  bone  and  forms  a 
flap  from  the  soft  parts  of  the  hypothenar  eminence  by 
incision  from  within  outward  (Fig.  103).  Often  the  flap  is 
cut  too  short.  The  operation  may  also  be  performed  with 
the  aid  of  an  oval  incision.  The  apex  of  the  oval,  as  well 
as  its  longitudinal  incision,  may  be  situated  either  upon  the 
dorsal  aspect  or  upon  the  ulnar  border  of  the  metacari:)us. 

Amputation  of  one  finger  through  the  metacarpus  is 
effected,  like  amputation  of  a  toe  through  the  metatarsus, 
through  an  oval  incision.  The  apex  of  the  oval  is  placed 
upon  the  dorsal  aspect  at  a  point  corresponding  to  the  site 
of  amputation.  The  longitudinal  incision  passes  along 
the  metacarpal  bone  somewhat  beyond  the  metacarpo- 
phalangeal joint,  where  it  encircles  the  finger  through  the 
flexor  fold,  to  ascend  on  the  opposite  side  and  meet  the 
longitudinal  incision.  The  muscles  are  detached  from  the 
metacarpal  l^one,  which  is  divided  with  the  phalangeal  or 
the  arched  saw.  The  peripheral  extremity  of  the  bone  is 
enucleated  and  removed  (Fig.  63). 


AMPUTATIONS  AM)  KS UCl.KATIONS. 


175 


Enucleation  of  all  four  finc/crH  fltroiif/h  the  meUuutrpdl 
bones  is  Ix'st  cftc'ctcd,  like  the  iinaloi^oiis  operation  upon 
the  foot,  through  a  short  dorsal  and  a  h)ng  pahnar  tej^u- 
nientarv  flap.  After  the  Haps  have  been  formed  the 
metacarpus  is  surrounded  with  a  circular  incision,  the 
muscles  in  the  interossc!ous  spaces  are  divided  with  a 
knife,  and  division  of  the  bones  is  effected  with  the  saw. 


Fig.  105. — Exarticulation  of  the 
hand :  circular  incision  in  two 
steps. 


Fig.  106.— Exarticulation  of 
the  hand :  dorsal  and  palmar 
flaps. 


The  oval  incision  also  may  be  advantageously  employed, 
the  apex  of  the  oval  being  situated  upon  one  or  other 
border  of  the  hand. 

Exarticulations  at  the  Wrist. — The  styloid  processes  of 
the  radius  and  the  ulna  constitute  the  bony  landmarks  for 
locating  the  line  of  the  wri.st-joint.  The  radiocarpal  joint, 
at  which  the  hand  is  removed,  corresponds  accurately  with 


176 


OPERA  TIVE  S  UR  GER  Y. 


a  transverse  line  upon  the  dorsum  of  the  hand  uniting  the 
two  styloid  processes,  when  the  hand  is  flexed  upon  the 
palm. 

Enudeation  of  the  Hand  by  Means  of  a  Circular  Incision 
and  the  Formation  of  a  Guff. — The  forearm  is  placed  in  a 
position  midway  between  pronation  and  supination.  The 
operator  occupies  the  same  position  as  in  amputation.     A 


Fig.  107.— Exarticulation  of  the  baud :    tegumentary  flap  formed  from 

the  thenar  eminence. 

circular  incision  is  made  through  the  skin  two  fingers' 
breadth  beyond  the  apex  of  the  styloid  process  of  the 
radius  (Fig.  105).  After  a  cuif  of  the  tissues  has  been 
dissected  back  the  tendons  are  divided  with  long  strokes 
of  an  amputation-knife.  The  operator  stands  at  the 
periphery  and  grasps  the  member  to  be  removed  with  his 
left  hand,  opening  the  wrist-joint  upon  its  dorsal  aspect, 


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8 


A  MP  I  rjw  Tfoys  A  yi>  kx  uclka  noys.         1 8 1 

while  tlic  liaiid  is  Iidd  in  :i  j)()siti(»ii  of  inaxiimiin  palmar 
flexion,  the  capsnlc  l)('ini>;  divided  npon  the  palmar  asjxct. 
The  radial  an<l  nlnar  arteries  are  divided  transversely  «»n 
the  palmar  aspeet  of  the  forearm  in  their  respective  snlci. 

EinicU'cition  of  the  Hand  by  Mcfuis  of  Flap-iiwrnonx. — 
The  apices  of  the  two  styloid  processes  form  the  extremities 
of  the  base  of  the  llaj).  The  dorsal  tegumentary  Hap 
(Figs.  106  and  108)  extends  to  the  middle  of  tlie  dorsum 
of  the  hand.  It  is  dissected  free  to  the  line  of  the  joint, 
which  is  opened  transversely  upon  its  dorsal  aspect.  The 
lateral  and  palmar  ligaments  are  divided,  when  the  ex- 
posed flexor  tendons  of  the  fingers  are  made  tense  by 
traction.  The  tendons  are  divided  transversely  and  a 
short  palmar  flap  is  formed  by  incision  from  within  the 
wound  outward  (Figs.  108  and  109). 

It  may  be  necessary  after  the  enucleation  of  the  hand 
to  use  the  integument  of  the  thenar  eminence  to  cover  the 
wound  (Fig.  107).  The  shape  of  the  tegumentary  flap  is 
outlined  by  incision,  the  flap  itself  dissected  free  from  the 
subjacent  structures,  and  from  its  extremities  a  circular 
incision  is  made  around  the  wrist-joint.  The  division  of 
the  tendons  and  the  disarticulation  of  the  hand  are 
effected  in  the  manner  described. 

Amputation  of  the  Forearm. — By  means  of  a  clrcnJar 
iiiL-i^ion.  The  arm  is  held  in  horizontal  abduction  from 
the  trunk  in  a  position  midway  between  pronation  and 
supination  in  such  a  way  that  the  thumb  is  directed  up- 
ward. A  circular  incision  is  made,  with  the  formation  of 
a  euft'  in  the  usual  manner.  The  muscles  are  divided, 
like  those  of  the  leg,  by  a  flgure-of-eight  incision  through 
the  interosseous  space.  In  applying  the  saw  the  forearm 
is  placed  in  a  position  of  complete  supination,  when  both 
bones  are  divided  simultaneously  from  the  palmar  aspect. 
In  the  transverse  section  thus  exposed  (Plate  10)  are 
seen  the  bone^,  and  th(\v  should  lie  parallel  in  a  position 
of  maximum  supination.  Between  the  ulna  and  the 
radius  is  stretched  the  interosseous  ligament,  with  the  in- 
terosseous artery  and  the  accompanying  vein  and  nerve 


182 


OPERATIVE  SURGERY. 


Plate  I o.— Transverse  Incision  through  the  Middle  Third  of 
the  Left  Forearm. 

r,  radius;  u,  ulna;  F.s.,  flexor  digitorum  sublimis;  P.p.,  flexor  digi- 
torum  profundus;  t^.i,  flexor  carpi  ulnaris;  i^.i.,  flexor  carpi  radialis; 
P.L,  palmaris  longus;  S.I.,  supinator  longus;  Ext,  group  of  extejisor 
muscles  ;  U,  ulnar  artery  in  a  common  sheath  with  the  corresponding 
veins  and,  the  ulnar  nerve ;  R,  radial  artery,  with  the  corresponding 
veins  and  nerve ;  M,  median  nerve ;  J,  interosseous  artery. 

on  its  palmar  aspect.  The  flexors  are  grouped  upon  the 
ulnar  and  palmar  aspect,  the  extensors  upon  the  radial 
and  dorsal  aspect  of  the  stump.  In  the  middle  of  the 
stump,  between  the  superficial  and  deep  groups  of  flexors, 
is  the  median  nerve,  divided  transversely.  In  the  con- 
nective-tissue interspace  in  which  the  nerve  is  contained 
lie  also  upon  either  side  the  ulnar  and  the  radial  artery. 
Of  flap-incisions  suitable  for  amputation  of  the  fore- 
arm the  best  consist  of  two  musculotegumentary  flaps  of 
equal  size  upon  the  palmar  and  dorsal  aspects.  A  single 
large  palmar  musculotegumentary  flap  may  also  be  ad- 
vantageously made  to  cover  the  wound  (Fig.  110). 


Fig.  110. — n,  flap-incision  for  amputation  of  the  forearm  ;  h,  exarticula- 
tiou  at  the  elbow-joint  through  a  circular  incision. 

Enucleation  at  the  Elbow-joint. — The  two  epicondyles 
are  palpable  on  either  side  of  the  joint,  and  just  below 
the  external  condyle  the  head  of  the  radius  can  be  felt 
upon  })ronation  and  supination  of  the  forearm.  The 
upper  border  of  the  radial  head  marks  the  situation  of  the 
articular  line. 


Tab.    10. 


LUh.  Anst  t: ReichJiold.  Miinchen. 


AMPUTATIOyS  AXD  EXi'CLEATIOyS. 


183 


The  enucleation  i.<  l)<\<t  etfei'ted  thruiigh  the  lorniation 
of  broad,  well-padded  inuseuloteguineiitarv  Haps  from  the 
sot\  tissues  of  the  Hexor  aspect  of  the  forearm.  The 
operator  grasps  with  his  left  hand  the  forearm  held  in  a 
position  of  maximum  supination.  A  long,  pointed  knife 
is  introduced  from  right  to  left  below  the  epicondyles  at 
th(^  level  of  the  articular  line  and  passed  transversely 
through  the  forearm  in  close  pmximitv  to  the  anterior 
surface  of  the  joint,  ^\'ith  sawing  movements  of  the 
knife  a  flap  is  formed,  which  extends  to  the  junction  of 
the  middle  and  upper  thirds  of  the  forearm  (Fig.  111). 
The  flap  is  reflected  upward  and  with  a  scalpel  the  ante- 
rior {X)rtion  of  the  capsule  of  the  elbow-joint  is  divided 


Fig.  111. — Exarticulatiou  at  the  elbow-joiut:  flap-incision. 


transversely,  so  that  the  trochlea  and  the  radial  head  of 
the  humerus  are  exposed.  With  the  elbow-joint  over- 
extended the  operator  divides  the  external  and  then  the 
internal  lateral  ligament.  Continuino:  the  over-extension 
the  olecranon  is  brouuht  into  the  wound.  The  attach- 
ment  of  the  triceps  muscle  is  dissected  close  to  the  bone 
and  a  short  tegumentary  flap  is  formed  upon  the  dorsal 
aspect  by  incision  from  within  the  wound  outward.  Up(^>n 
the  flexor  aspect  the  two  branches  of  the  brachial  artery 
are  to  be  ligated. 

The  circular  incision  for  exarticulatiou  of  the  elbow- 
joint  is  made  abt)ut  three  or  four  fingers'  breadth  below 
the  line  of  the  articulation,  and  a  cutY  is  dissected  in  the 
usual  manner  to  the  level  of  this  line  and  reflected  up- 


184 


OPERATIVE  SURGERY 


Plate  11.  — Transverse  Incision  through  the  Right  Arm  at  its 

Middle  Third. 

B,  biceps  muscle  ;  Br.  i.,  brachialis  anticus  ;  T,  triceps  ;  A.  h.,  brachial 
artery  in  a  common  sheath  with  the  corresponding  vein  and  the  median 
ner\"e  {M}  ;  U.,  ulnar  nerve  ;  i?.,  radial  nerve ;  M.  c,  musculocutaneous 
nerve. 

ward.  The  joint  is  opened  and  the  exarticnlation  effected 
in  the  manner  described. 

Amputation  of  the  Arm. — ^^A  circular  incision  may  be 
employed,  as  well  as  the  formation  of  two  musculotegu- 
mentarv  flaps. 

The  circular  incision  (Fig;.  112)  is  made  either  in  the 
customary  manner  in  two  steps,  with  the  formation   of  a 


\ 


Fig.  112. — Amputation  of  the  arm:  circular  incision. 

cuflP,  or  with  a  sincrle  stroke  of  the  knife  after  the  soft 
parts  have  been  vigorously  retracted.     In  the  stump  of 


Tab    11. 


Brj  —^ 


I 
T. 


Ldh,A/iSl  r  Htunnvui  Mun^fir'^ 


AMI' UTA  TIOSS  A SD  ES UCLEA  TIOXS. 


18o 


the  amputation  (Plate  11)  the  brachial  arten-  is  to  be 
ligiited  in  the  interval  between  the  Ijieep.-?  an<l  triceps 
inus<^-le5.  The  radial  nerve,  whieli  jia.sses  throujrh  the 
triceps  muscle  in  the  outer  }Kjrtion  of  the  stump,  is  accom- 
panied by  an  arterv. 

Of  tfnp-inri.sion.s  the  most  useful  consists  in  the  forma- 


tion of  an  internal  and  an  external   musculoteguuieutar)' 


1 


Flap-incisions  for  amputation 
the  arm. 


leation  of 


flap.  The  flaps  meet  anteriorly  upon  the  biceps  muscle 
and  posteriorly  over  the  middle  of  the  triceps.  The  int<*r- 
nal  flap  cnntains  tin-  l>ni  hial  arteiy-  (Figs.  113  and  114). 
Exarticulation  of  the  Humerus. — In  oix-ratious  ujxju  the 
shoulder,  as  in  operations  about  the  hiivjoint,  the  applica- 
tion of  the  Esmarch  bandage  to  control  hemorrhage  is 
attended   with   considerable  difficulty,  and   the    methods 


186 


OPERATIVE  SURGERY. 


employed  are  modified  accordingly.  The  artery  is  either 
ligated  in  advance,  or  it  is  divided  at  the  last  stage  of  the 
operation  while  digital  compression  is  made. 

Exarticulation  by  Means  of  a  Deltoid  3Iusculotegu- 
mentary  Flap. — The  trunk  of  the  subject  is  elevated  and 
the  operator  outlines  a  flap  in  the  deltoid  region  with  a 
U-shaped  incision   whose    upper   extremities  correspond 


/ 


Fig.  115. — Exarticulation  of  the  humerus:  formation  of  an  axillary mus- 
culotegumeutary  flap  by  iucision  from  within  the  wound  outward. 

with  the  acromion  and  the  apex  of  the  coracoid  process, 
and  which  extends  as  low  as  the  insertion  of  the  deltoid 
muscle  (Figs.  113  and  114).  After  the  tissues  are  divided 
down  to  the  muscles  the  flap  retracts  somewhat.  The 
musculotegumentarv  flap  is  dissected  from  the  bone  by. 
long  strokes  of  the  knife.  By  dissection  of  the  flap  the 
shoulder-joint  is  exposed.     The  operator  grasps  the  arm 


AMPVTATIOSS  AyD  ENUCLEATIUSS. 


187 


with  his  loft  hand,  and  divides  the  oaj)sulo  of  the  joint  by 
applyinir  tlic  knife  vertically  upon  the  head  of  the  humerus 
and  passing  it  in  an  arehed  direction  over  the  most  promi- 
nent convexity  of  the  bone  (Fig.  117).  The  head  of  the 
humerus  is  forced  out  of  tlie  wound,  the  attachment  of 
the  ])osterior  wall  of  the;  capsule  se])arated  from  the  l)one, 
and  the  surgical  neck  of  the  humerus,  as  well  as  the  upper 


Fig.  116. — Exarticulation  of  the  humerus  by  a  combination  of  circular 
and  longitudinal  incisions. 

extremity  of  the  shaft  of  the  bone,  is  freed  from  the  soft 
tissues.  In  this  way  a  bridge  is  formed  of  the  soft  tissues 
of  the  axilla  in  which  the  ves.sels  are  contained.  While 
an  assistant  grasps  this  bridge  between  the  thumb  and 
index-finger  of  each  hand  in  such  a  way  as  to  compress 
the  artery,  a  flap  is  cut  from  the  .<oft  tissues  of  the  axilla 
at  a  level  corresponding  with  the  attachment  of  the  pecto- 


188  OPERATIVE  SURGERY. 

ralis  major  muscle  to  the  humerus  from  within  the  wound 
outward  (Fie.  Ho).  AVhile  the  digital  compression  is 
continued,  the  axillarv  arterv  is  Halted.  At  the  inner 
side  of  the  deltoid  flap  Ijmnches  of  the  posterior  circumflex 
arterv  are  to  be  secured  bv  ligature. 

Exarticidation  by  Cleans  of  a  Circular  Incision  in  Con- 
junction tcith  a  Longitudinal  Incision  by  Esmarch's 
Method. — The  arm  is  surrounded  at  the  higliest  point 
possible  by  an  Esmarch  tube.  The  patient  occupies  a 
similar  position  to  that  for  amputation  of  the  arm.  A 
circular  incision  is  made  through  the  skin  below  the  at- 
tachment of  the  deltoid  muscle,  and  at  the  point  of  retrac- 
tion the  muscles  are  divided  circularly  and  the  bone  is 
sawed  through.  Hemorrhage  from  the  divided  surface 
is  controlled  and  the  elastic  tube  is  removed.  The  body 
of  the  su])ject  is  raised  still  hiofher  and  a  luncritudinal 
incision  is  made  from  the  coraco-acromial  furrow  down  to 
the  wound  (Fig.  116).  The  incision  passes  through  the 
deltoid  muscle  and  exposes  the  capsule  of  the  joint.  The 
margins  of  the  incision  are  separated  by  tenacula  and  the 
muscle  is  detached  from  the  shaft  of  the  bone.  The  joint 
is  opened  in  the  manner  described  and  the  bone  is  sepa- 
rated carefully  from  its   attachments  (Fig.  117). 

An  or(d  incision  may  also  be  employed  in  operations 
at  the  shoulder-joint  in  such  a  way  that  the  longitudinal 
portion  of  the  incision  is  made  from  a  point  midway  be- 
tween the  coracoid  and  acromion  processes  to  the  insertion 
of  the  deltoid,  through  the  muscle  down  to  the  j<:)int,  while 
the  transverse  incision  througli  the  flexor  aspect  passes 
only  through  the  skin.  The  margins  of  tlie  longitudinal 
incision  are  separated  by  tenacula,  tlie  joint  is  opened,  and 
the  head  and  the  neck  of  the  humerus  are  exposed  and 
forced  out  of  the  wound.  While  the  artery  is  compressed 
in  the  wound  the  operator  cuts  the  base  of  the  oval  to- 
ward the  axillarv  cavitv  in  the  incision  previouslv  outlined. 


AMPl'TATIOXS  Ayj>    EM'CLEATKJSS.  189 


Fig.  117. — Exarticulation  of  the  humerus   by  Esmarch's   method;    di- 
vision of  the  articular  capsule. 


IlE^J'XrWS^  AT  JOISTS  OF  THE  EXTRKMITIEIS.    191 


III.    Resections  at  the  Joints  of  the  Extremities. 

By  resection  of  a  joint  is  understood  the  systematic 
removal  of  its  constituent  parts,  with  conservation  of 
contiguous  structures.  In  the  presence  of  tuberculous 
disease,  as  well  as  of  severe  injuries  about  the  large 
joints,  resection  promised  to  be  a  conservative  substitute 
for  amputation.  It  can  thus  be  realized  that  this  mode 
of  procedure  Avas  expected  to  prove  a  great  advance  in 
surgery,  in  times  of  both  "war  and  peace.  The  methods  of 
operation  were  so  selected  that  compensation  for  the  loss 
of  the  parts  removed  could  reasonably  be  hoped  for. 
AVith  this  thought  Langenbeck  devised  operations  for  all 
of  the  joints  in  which  the  capsule  was  permitted  to  retain 
its  connection  with  the  periosteum,  for  whose  osteoplastic 
capability  experimental  proof  had  been  furnished  (sub- 
periosteal resection).  Langenbeck's  incisions  are  still 
largely  used  in  the  performance  of  resections.  The  intro- 
duction of  asepsis,  as  well  as  a  more  precise  knowledge 
concerning  the  nature  and  the  distribution  of  the  tubercu- 
lous process  in  joints,  has  changed  our  views  of  these 
operations  fundamentally.  Antisepsis  has  rendered  pos- 
sible conservative  treatment  Avith  success  of  injuries  to 
joints,  even  without  resection,  for  which  previously 
amputation  would  have  been  undertaken.  The  nature  of 
the  tuberculous  process  and  the  extent  of  its  distribution 
in  the  joints,  further,  make  it  undesirable  to  adopt  the 
routine  plan  of  procedure  in  every  case  of  removing  the 
bones  entering  into  the  constitution  of  the  joint,  while  the 
capsule  as  such  is  permitted  to  remain.  Resection  of 
tuberculous  joints  is  no  longer  regarded  as  a  typical  pro- 
cedure to  be  employed  in  every  case,  as,  for  instance,  is  the 
extirpation  of  tumors  ;  nevertheless,  opening  of  the  joints 
of  the  dead  subject  in  a  typical  manner  is  practised,  as  by 
this  means  the  surgeon  familiarizes  himself  with  methods 
by  which  it  is  possible  to  o])en  the  joints  with  great  care, 
and  which  render  accessible  throughout  their  whole  extent 


192  OPERATIVE  SURGERY, 

the  parts  that  enter  into  the  formation  of  the  joint,  as  well 
as  the  synovial  surfaces  of  the  capsule.  Thus,  in  a  certain 
sense,  the  preliminary  operation  is  performed,  with  which 
clinically  in  the  individual  case  the  special  operation  of 
removal  of  tuberculous  disease  is  conjoined.  The  capsule 
of  the  joint  is  widely  opened  [cuihrotomy),  the  synovial 
sac  freed  throughout  its  w^hole  extent,  and  in  accordance 
with  the  extent  of  the  morbid  process  the  extirpation  of 
the  synovia  (^synovial  artJrrecfomy),  excochleation  of  areas 
of  bone,  possibly  after  exposure  by  means  of  the  chisel 
and  mallet,  or  resection  of  the  articular  extremities  (os- 
seous arthredomy)  is  undertaken.  When  the  disease  is  ad- 
vanced the  bones  are  sawed  through.  In  some  joints 
division  of  one  of  the  bones  entering  into  the  articulation 
w^ith  a  saw  must  be  undertaken  in  order  that  the  joint  may 
be  made  accessible  throughout  its  whole  extent  for  the 
effectuation  of  the  necessary  operative  measures. 
Indications : 

1.  Injuries,  complicated  destruction  of  the  constituents 
of  the  joint,  especially  if  large  portions  of  bone  are  com- 
pletely severed  from  their  attachments. 

2.  Tuberculosis  of  joints,  if  conservative  measures  (rest 
and  fixation  of  the  joint,  treatment  with  iodoform,  blood- 
stasis,  minor  local  measures)  have  failed. 

3.  Deformities  of  the  joints.  Orthopedic  resections  for 
the  correction  of  severe,  otherwise  irreparable  alterations 
in  form  (contractures,  ankyloses). 

4.  Luxaiions,  if  irreducible  and  attended  Avith  marked 
limitation  of  function. 

5.  Acute  infiammatory  processes  in  bones,  osteomyelitis 
with  epiphyseal  separation  and  suppuration  of  the  affected 
joint. 

6.  Flail-joints  which  it  is  desired  toankylose  artificially 
(arthrodesis). 

The  incisions  are  made  with  short,  strong  knives, 
through  the  soft  parts,  down  to  the  bone.  After  division 
of  the  capsule  this,  together  with  the  periosteum,  is  sep- 
arated from  its  attachment  to  the  bone  and  the  latter  is 


RESECTIOXS  AT  JOIXTS  OF  THE  EXTREMITIES.    193 

divided  with  tlio  saw.  The  ineisions  tliroiigh  the  soft 
parts  are  so  arranged  that  transverse  division,  espeeially  of 
muscles,  tendons,  large  nerves  and  vessels,  is  so  far  as 
possible  avoided.  Langenheck's  incisions  for  resection 
correspond  mostly  with  the  longitudinal  axis  of  the  ex- 
tremities. The  articular  capsule  is  opened  as  freely  as 
possible  in  the  direction  of  the  cutaneous  incision.  The 
margins  of  the  wound  in  the  capsule  being  separated 
widely  by  means  of  tenacula,  the  operator  ])egins,  by 
means  of  a  series  of  closely  approximated  incisions  with 
a  resection-knife,  which  is  always  applied  vertically  upon 
the  bone,  to  separate  the  attachments  of  the  capsule  to- 
gether with  the  periosteum.  The  bones  are  forced  out  of 
the  wound  and  divided  by  means  of  the  arched  saw,  the 
metacarpal  saw,  or  the  wire  saw,  or  the  chain-saw.  The 
plane  of  the  sawed  surface  varies  with  the  individual 
joints. 

For  the  correction  of  angular  contractures  wedge-shaped 
excision  of  bones  is  necessary.  In  place  of  this,  arch- 
shaped  resection  (Helferich)  may  be  employed,  in  con- 
junction with  which  the  shortening  is  slighter. 

After  resection  of  the  bone  has  been  effected  the  sawed 
surfaces  are  brought  in  apposition  and  fixed  by  means  of 
nails  or  clamps,  or  even  without  these  in  a  bandage.  The 
division  of  the  capsule,  of  the  muscles,  and  of  the  skin 
is  closed  by  sutures.  By  the  introduction  of  drainage- 
tubes  or  of  capillary  drains  escape  of  possible  secretion 
is  ])rovided  for. 

Resections  of  the  Joints  of  the  Upper  Extrem- 
ity.— Resection  of  the  Shoulder-joint  by  the  Method  of 
Langenbeck. — The  patient  is  placed  upon  the  operating- 
table  in  a  sitting  posture  in  such  a  manner  that  the 
shoulder  projects  somewhat  beyond  the  border  of  the 
table.  The  operator  stands  upon  the  side  of  the  trunk, 
with  his  face  directed  toward  the  shoulder.  He  grasps 
the  upper  arm  at  its  middle  with  the  left  hand  and  with 
the  arm  hanging  naturally  he  enters  the  resection-knife 
held  almost  vertically  into  the  coraco-acromial  trigone 
13 


194 


OPERATIVE  SURGERY. 


(Fig.  11).  The  incision  is  made  in  the  lonofitudinal  axis 
of  the  arm  through  the  deltoid  muscle  almost  to  its  inser- 
tion into  the  humerus  and  down  to  the  capsule  (Fig.  118). 
The  upper  extremity  of  the  incision  divides  the  tense 
band  between  the  acromion  and  coracoid  processes.  After 
the  margins  of  tlie  wound  have  been  widely  separated  by 
hooks  the  lateral  ^^all  of  the  capsule  is  exposed.  With 
slisrht  rotaticm  outward  of  the  arm  the  tuberosities  of  the 


Fig.  113. — Resoctidn  of  the  shoulder:  longitudinal  incision. 

humerus  and  the  bicipital  groove  are  brought  to  the  level 
of  the  wound.  The  capsule  is  incised  and  divided  upon 
a  o;rooved  director  in  a  line  corresponding  to  this  groove 
upward  to  the  glenoid  cavity,  and  downward  to  the  sur- 
gical neck  of  the  humerus.  The  tendon  of  the  biceps 
thus  exposed  is  raised  from  its  bed  by  means  of  blunt 
hooks  and  displaced  inward  over  tlie  head  of  the  humerus. 
From  thiG  incision  in  the  capsule  made  to  free  the  tendon 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    195 


BEiiECTIOyS  AT  JUIST:^   UF  TllK  EXTliEMlTIES.    1'J7 


Fig.  120. — Eesection  of  the  shoulder:  division  of  the  head  of  the 
humerus  with  the  saw  ;  the  head  of  the  boue  is  fixed  by  means  of  Lau- 
geubeck's  forceps. 


nESEcrioxs  at  joints  of  the  extremities.  199 

of  the  biceps  the  separation  of  the  capsule  from  tlie  bone 
is  nndertakon.  Witli  the  aid  of  a  liook  introduced  into 
the  slit  in  the  capsule  the  latter  is  elevated  and  dissected 
free  from  the  humerus  close  to  the  bone.  The  operator 
progresses  step  by  stepj  while  the  arm  is  rotated  toward 
the  knife.  After  the  capsule  has  been  divided  through- 
out half  of  its  circumference  the  remainder  is  similarly 
detached  from  the  bone,  tlie  operator  proceeding  from  the 
original  slit  in  the  capsule  in  the  oj)posite  direction.  In 
connection  with  the  capsule,  into  whose  formation  enter 
fibers  of  the  shoulder-muscles  (supraspinatus,  infraspina- 
tus, subscapularis),  the  latter  are  at  the  same  time  de- 
tached from  the  bone  at  their  insertion.  ^Vhen  the  head 
of  the  bone  has  been  thus  freed  it  is  lifted  out  of  the 
Avound  (Fig.  119),  and  divided  at  the  level  of  the  surgical 
neck  of  the  humerus  by  means  of  the  chain-saw,  or,  after 
being  fixed  with  Langenbeck's  forceps,  with  the  arched 
saw  (Fig.  120).  The  tendon  of  the  biceps  muscle  is  by 
this  procedure  preserved  intact.  After  removal  of  the 
head  of  the  humerus  the  glenoid  cavity,  as  well  as  the 
whole  interior  of  the  capsule,  is  sufficiently  exposed  for 
whatever  further  operative  procedures  may  be  necessary. 
Vessels  of  considerable  size  are  not  injured  in  per- 
forming resection  of  the  shoulder  through  a  longitudinal 
incision. 

Resection  of  the  Elbow-joint  through  a  Dorsal  Longi- 
tudinal Incision. — The  arm  is  flexed  at  a  right  angle  at 
the  elbow-joint  and  thrown  over  the  thorax  in  such  a 
manner  that  the  extensor  aspect  of  the  joint  is  turned  up- 
ward. The  operator  stands  upon  the  side  of  the  thorax 
that  corresponds  witli  the  healthy  member.  The  incision 
is  made  upon  the  doi^al  aspect  of  the  joint  through  the 
lower  extremity  of  the  triceps  muscle  over  the  olecranon 
(Fig.  122).  Langenbeck  makes  this  longitudinal  incision 
rather  nearer  the  inner  border,  while  C'hassaignac  makes 
it  upon  the  outer  border  of  the  olecranon,  although  it 
may  also  be  made  satisfactorily  in  the  middle  line  (Park). 
The  incision  passes  through  the  triceps  muscle  down  to 


200 


OPERATIVE  SURGERY. 


the  bone.  While  the  lips  of  the  Avoiind  in  the  mnscle  are 
energetically  separated  by  means  of  hooks,  the  posterior 
wall  of  the  capsule  of  the  elbow-joint  bulges  into  view 
and  is  divided  in  the  direction  of  the  cutaneous  incision. 
With  strokes  of  the  knife  directed  vertically  toward  the 
bone  the  tendon  of  tlie  triceps  is  detached  from  the  olec- 
ranon close  to  the  bone.     At  the  same  time  the  muscles 


Fig.  121.— Eesection  of  the  elbow-joiut:  exposure  of  the  elbow-joint 
on  its  inner  aspect ;  the  olecranon  and  the  inner  extremity  of  the  troch- 
lea come  into  view ;  the  ulnar  nerve  has  slipped  from  the  inner  epicon- 
dyle  after  retraction  of  the  margin  of  the  wound. 

inserted  upon  the  dorsal  aspect  of  the  upper  extremity  of 
the  ulna  are  detached  in  conjunction  with  the  periosteum. 
Upon  the  outer  side  the  radial  head  of  the  humerus  and 
the  head  of  the  radius  come  into  view,  and  the  strong 
fibrous  lateral  ligament  is  to  be  freed  close  to  the  bone. 
On  the  inner  side  the  detachment  of  the  tendon  of  the 
triceps  from  the  olecranon  is  begun.  At  the  same  time 
the  muscles  are  dissected  free  also  from  the  upper  ex- 


EESECTIoyS  AT  JOINTS  OF  THE  EXTREMITIES.    201 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    203 

tremity  of  the  ulna,  ^^'llik'  the  frco  niar<rin  of  the  wound 
is  drawn,  tlirougli  marked  flexion  at  the  elbow-joint,  in- 
ward and  toward  the  flexor  aspect,  the  inner  e})i('ondyle 
of  the  humerus  aj)pears  within  the  field  of  operation. 
The  museles  attached  to  tliis  ])roeess  (pronator  radii  teres 
and  flexors  of  the  hand  and  of  the  fingers)  should  also  be 
detached  close  to  the  bone.  In  order  not  to  injure  the 
ulnar  nerve  dislocated  from  its  place  on  the  trochlea  by 


Fig.  125. — Resection  of  the  elbow-joint :  the  constituent  parts  of  the 
elbow-joint  are  completely  exposed  and  pushed  out  of  the  longitudinal 
incision. 


the  side  of  the  inner  epicondyle,  the  detachment  of  the 
muscles  from  the  inner  epicondyle  is  carried  out  in  such  a 
manner  that  the  semicircular  incisions  are  made  to  pass 
close  together  from  the  apex  of  the  epicondyle  to  the  base 
of  this  bone  (Fig.  121).  In  this  manner  the  ulnar  ners^e 
is  kept  entirely  out  of  reach  of  the  knife.  By  further  dis- 
section the  inner  margin  of  the  trochlea  and  the  sigmoid 
cavity  of  the  ulna  are  freed.  When  the  separation  of  the 
capsule  has  extended  beyond  the  attachments  of  the  iat- 


204 


OPERATIVE  SURGERY. 


eral  ligaments  the  articular  extremity  of  the  humerus,  as 
Avell  as  those  of  the  bones  of  the  forearm,  can  be  forced 
out  of  tlie  wound  (Fig.  125).  The  bones  are  grasped 
with  Langenbeck's  forceps  and  sawed  through,  the  hu- 
merus above  the  trochlea,  the  bones  of  the  forearm  simul- 
taneously upon  the  distal  side  of  the  head  of  the  radius 
and  the  coronoid  process. 

In  describing  the  steps  of  the  operation  its  performance 
upon  the  dead  subject  has  been  kept  in  view.  In  actual 
clinical  experience  the  mode  of  procedure  is  subjected  to 


Fig.  126. — Eesection  of  the  wrist-joint:  dorsoradial  incision;  the  ex- 
tensor tendons  are  displaced  to  one  side  ;  the  lower  extremity  of  the 
radius  and  the  two  rows  of  carpal  bones  are  exposed  to  view. 

certain  modifications.  Thus,  the  disarticulation  and  the 
isolated  division  of  the  bones  with  the  saw  may  be  omitted 
in  the  treatment  of  cases  of  ankylosis  of  the  joint. 


other  J'arieties  of  Eesection  of  the  EJbov-joint. — A  longitudinal  incision  is 
made  on  either  side  of  the  joint  (Vogt,  Hueter) ;  or  an  H-shaped  incision 
is  made  (Moreau),  the  transverse  portion  dividing  the  tendon  of  the  tri- 
ceps above  its  attachment;  or  a  transverse  incision  is  made  upon  the  ex- 
tensor aspect  of  the  joint  over  the  olecranon  process,  with  temporary 
transverse  division  of  the  olecranon  with  a  saw  (Szymanowsky,  Bnins) ; 
or  a  bayonet-incision  is  made  (Oilier)  (Fig.  123). 


RESECTIOXS  AT  JOLXTS  OF   Till-:  EXTREMITIES.    205 

Koc'her's  anpiiliir  incision  passes  fi-r»n»  the  outer  aspect  of  the  lower  ex- 
ironiity  of  the  liunieriis,  parallel  with  tlie  axis  of  the  hiinieriis,  to  the 
head  of  the  radius.  From  this  point  it  continues  alonj^  the  outer  horder 
of  the  anconeus  muscle  to  the  l)order  of  the  ulna  from  4  to  <!  cm.  helow 
the  apex  of  the  olecranon  (Fij;.  124).  Tlie  olecranon  is  br»»ken  (tff  with 
the  chisel  and  removed,  or  the  muscles  are  separated  from  that  process. 
Kocher  saws  throujih  the  bones  in  an  arclied  manner. 

Resection  of  the  Wrist-joint. — Dorsoradial  Incision   by 
Langenbeck\s  Method. — A  cutaneous  incision  is  made  upon 


Fig.  127. 


-Eesection  of  the  wrist-joint :  Langeubeck's  dorsoradial 
incision. 


the  dorsal  aspect  from  tlie  middle  of  the  ulnar  border  of 
the  metacarpal  l)one  of  the  iiidex-fintrer  to  the  middle  of 
the  lower  extremity  of  the  radius  (Fig.  127).  The  inci- 
sion passes  between  the  tendons  of  the  extensor  digitorum 
communis  and  the  extensor  hallucis  longus,  and  divides 
the  dorsal  transverse  ligament  of  the  carpus.     The  attach- 


206  OPERATIVE  SURGERY. 

ments  of  the  radial  extensor  muscles  are  separated  from 
the  base  of  the  metacarpal  bones  and  the  radiocarpal  joint 
is  opened.  By  means  of  a  knife  or  a  sharp  raspatory  the 
capsule  of  the  joint  is  freed  from  the  dorsal  aspect  of  the 
bones  at  the  root  of  the  hand,  the  individual  small  joints 
opened,  and  the  bones  extirpated  singly  (Fig.  126). 

The  dorso-ulnar  incision  (Lister)  for  resection  of  the 
Avrist-joint  is  made,  with  slight  radial  flexion  of  the  hand, 
from  the  middle  of  the  fifth  metacarpal  bone,  over  the 
middle  of  the  wrist-joint,  beyond  the  radial  epiphysis. 
The  dorsal  transverse  ligament  of  the  carjDus  is  divided, 
when,  by  the  side  of  the  extensor  tendons  of  the  finger 
retracted  toward  the  radial  aspect,  access  to  the  joint  is 
gained.  At  the  base  of  the  fifth  metacarpal  bone  the  ten- 
don of  the  extensor  carpi  ulnaris  must  be  detached  from 
the  bone.  Xow  the  attachment  of  the  capsule  may  be 
freed,  beginning  at  the  ulna,  when  the  carpal  bones  are 
exposed  and  removed  individually.  If  it  be  necessary  to 
remove  also  the  epiphysis  of  the  radius,  this  is  forced  out 
of  the  wound,  grasped  by  its  styloid  process  with  Langen- 
beck's  forceps,  and  divided  transversely  with  the  saw. 

Another  method  of  resection  of  the  wrist-joint  consists  in  making  a 
longitudinal  incision  on  either  side,  or  an  H-shaped  incision,  according  to 
Gritty.  The  transverse  incision  upon  the  dorsum  of  the  hand  severs  the 
tendons. 

Resection  of  the  Fingers. — Resection  at  the  metacarpo- 
phalangeal joints  of  the  thumb,  the  index  and  the  little 
fingers,  as  well  as  at  the  interphalangeal  joints,  is  effected 
through  a  lateral  incision,  thus  completely  protecting  the 
extensor  as  well  as  the  flexor  tendons.  The  incision  opens 
the  joint  laterally.  The  capsular  attachments  are  sepa- 
rated upon  the  dorsal  and  palmar  aspects  of  the  bone,  and 
the  articular  extremities  of  the  bones  are  forced  out  of  the 
wound  and  divided  with  the  saw.  After  removal  of  the 
bones  the  s\Tiovial  surface  of  the  joint  is  completely  ex- 
posed. The  metacarpophalangeal  joint  of  the  thumb  be- 
comes accessible  only  after  separation  of  the  muscles  of 
the  thenar  eminence.     The  metacarpoplialangeal  joints  of 


RESECTfOys  AT  JOISTS  OF  THE  EXTREMITIES.    207 

the  middle  and  rinir-tinirors  arc  exposed  hv  means  of  dor- 
sid  longitudinal  ineisions,  the  opening  of  the  jnint  and  the 
removal  of  the  artieular  extremities  being  effected  in  the 
tvpieal  manner.  Resection  (jf  an  entire  metacarpal  bone 
is  effected  through  a  dorsal  longitudinal  incision  extend- 
ing from  the  base  to  the  head  of  the  bone,  which  is  ex- 
posed bv  subj)eriosteal  detachment  of  the  interosseous 
muscles  on  either  side,  j\jid  is  raised  from  its  surroundings 
after  the  joint  at  its  base  and  that  at  its  head  have  been 
opened  (Fig.  104).  The  resection  of  entire  phalanges  is 
effected  throuLih   lateral  loULritudinal  ineisions. 

Resection  of  the  Joints  of  the  lyower  Extremi- 
ties.— Resection  of  the  Hip-joint. — Exicrnal  Longitudinal 
Incii<ion  by  the  Method  of  Langenbech. — The  patient  to  be 
ojxTated  upon  lies  upon  the  unaffected  side.  The  diseased 
extremity  is  flexed  at  an  obtuse  angle  and  held  in  a  posi- 
tion of  slight  adduction.  The  incision  passes  from  the 
posterior  su|)erior  iliac  spine  parallel  with  the  long  axis 
of  the  extremity  over  the  greater  trochanter,  and  continues 
at  once  through  the  gluteal  muscles  down  to  the  iliac  bone 
and  the  articular  capsule.  The  tendons  inserted  into  the 
trochanter  are  detached  close  to  the  bone  on  both  sides, 
the  capsule  is  divided,  and  the  articular  cartilage  at  the 
margin  of  the  acetabulum  incised.  The  knife  is  intro- 
duced into  the  opening  into  the  joint  and  the  round  liga- 
ment divided  while  the  member  is  held  in  a  position  of 
forced  flexion,  adduction,  and  internal  rotation.  In  this 
way  the  head  of  the  femur  is  made  to  lie  upon  the  iliac 
bone.  The  chain-saw  is  passed  around  the  neck  of  the 
femur  and  the  head  of  the  bone  is  thus  divided. 

External  Arched  Incision  by  the  Method  of  Velpeau. — 
The  patient  occupies  the  same  position  as  in  Langenbeck's 
o|>eration.  The  resection-knife  is  introduced  at  a  point 
midway  between  the  anterior  superior  iliac  spine  and  the 
apex  of  the  trochanter,  vertically,  down  to  the  concavity 
of  the  ilium.  The  incision  surrounds  the  anterior  three- 
fourths  of  the  ]x*ri]ihery  of  the  trochanter  and  at  all  }x>ints 
extends  down  to  the  bone  (Fig.  128).     Care  should  be 


208  OPERATIVE  SURGERY. 

taken  that  the  ghiteal  muscles  are  divided  in  a  vertical 
direction.  If  the  margins  of  the  wound  are  separated  at 
its  depth,  the  fibrous  capsule  of  the  joint  becomes  visible. 
Over  the  highest  prominence  of  the  liead  of  the  femur 
the  capsule  is  divided  by  an  arched  incision  corresponding 
with  the  cutaneous  incision.  The  articular  cartilai>:e  is 
incised  and  after  division  of  the  ligamentum  teres  the 
head  of  the  femur  is  luxated  upon  the  ilium  and  removed. 


Fig.  128. — Eesection  of  the  hip:  external  arched  incision  by  the  method 

of  Velpeau. 

If  the  removal  of  the  head  is  to  be  effected  at  a  higher 
point  between  the  trochanters,  or  on  the  shaft  of  the  femur, 
the  tendons  inserted  into  the  trochanters  must  be  detached 
from  the  bone  with  the  knife.  After  the  head  of  the 
bone  has  been  sa^ved  off  the  acetabulum  is  exposed  for 
such  further  surgical  interference  as  may  be  necessary. 
The  extremity  is  placed  in  an  extended  position  and  a 
drainage-tube  is  passed  into  the  depths  of  the  acetabulum. 

Konig  has  modified  Langeuheck's  operation  })y  removing  with  a  chisel 
the  liead  of  the  femur  vi  situ  before  it  is  hixated.  Further,  tlie  attach- 
ments of  the  muscles  to  the  greater  trochanter  are  not  separated  from 
the  bone,  but  are  removed,  in  conjunction  with  the  cortical  structure  of 


RESECTIOA'S  AT  JOJSTS  OF  THE  EXTREMITIES.    209 

the  troch;iiitcr  upon  its  anterior  and  posterior  sides,  with  chisel  and 
mallet. 

Liicke's  and  Seliede's  anterior  longitudinal  incision  jiasses  downward 
from  the  anterior  sujierior  iliac  spine.  The  joint  is  entered  to  the  outer 
side  of  the  erural  nerve. 

The  anterior  transverse  incision  of  Roser  is  attended  with  the  disad- 
vantage that  the  libers  of  numerous  muscles  are  divided  transversely. 

Resection  of  the  Knee-joint  through  an  Anterior  Trans- 
verse  Incision. — The  operator  grasps  the  leg  of  the  ex- 


FiG.  129. — Resection  of  the  knee-joint:  anterior  arched  incision  by  the 

method  of  Textor. 

tremity  flexed  at  the  knee-joint  and  unites  the  most 
prominent  points  on  the  lateral  aspects  of  the  condyles 
of  the  femur  by  an  anterior  arched  incision  passing  from 
left  to  right  and  dividing  the  patellar  ligament  (Textor, 
Fig.  129).  The  incision  enters  the  joint,  which  is  opened 
adequately  upon  its  anterior  aspect  (Fig.  130).  The 
thumb  of  the  left  hand  is  passed  into  the  articular  interval 
between  the  patella  and  the  femur,  and  separates  the  at- 

14 


210 


OPERATIVE  SURGERY. 


tachments  of  the  capsule  laterally  to  the  condyles  of  the 
femur,  when  by  reflecting  the  patella  the  sacculated  diver- 
ticulum of  the  capsule  is  visible  from  above.  The  crucial 
ligaments  and  the  accessory  lateral  ligaments  are  now 
divided.  The  lower  extremity  of  the  femur  is  thus 
exposed  and,  after  the  perio.-teum  has  been  incised  cir- 


FiG.  130. — Knee-joint  opened  through  the  anterior  arched  incision. 


cularly  above  the  condyles,  the  bone  is  fixed  with  Langen- 
beck's  forceps  and  divided  transversely.  Konig  makes 
the  saAved  surfaces  in  such  a  })]ane  that  the  joint  is  placed 
in  a  position  of  slight  flexion.  If  it  be  necessary  to  re- 
move also  the  ipper  articular  surface  of  the  tibia,  this  is 
brought  out  of  the  wound,  surrounded  by  a  circular 
incision,  and  removed  in  the  fonn  of  a  plate.     In  sawing 


RESECTFoys  AT  JOINTS   OF  THE  EXTREMITIES.    211 

the  bone  it  is  o;ras])0(l  witli  tho  f<)rce])s  at  the  intercondyloid 
oniiiU'iu'c  and  fixed.  It"  the  patella  in  to  he  removed,  it 
is  surrounded  by  an  incision  and  treed  with  strokes  of  the 
knife  passed  close  to  the  bone.  The  sawed  surfaces  of 
the  bones  are  approximated  and  fixed  in  apposition  by 
means  of  sutures,  clamps,  or  \)v^s. 

According  to  the  method  of  Volkmann,  the  anterior 
transverse  incision  passes  from  one  condyle  to  the  other 
over  the  middle  of  the  patella.  The  periosteum  is  in- 
cised transversely  and  the  patella  is  sawed  through  on  a 
line  with  the  cutaneous  incision.  In  the  prolongation  of 
the  incision  through  the  patella  the  capsule  is  incised  to 
the  right  and  the  left  and  the  joint  is  widely  opened.  The 
knee  is  now  strongly  flexed  at  an  acute  angle,  so  that  the 
incision  into  the  joint  is  made  to  gape  widely  and  the 
lateral  ligaments,  as  well  as  the  lateral  attachments  of 
the  capsule,  are  divided.  The  crucial  ligaments  are 
divided  from  behind  forward.  The  upper  segment  of 
the  patella  is  reflected  by  traction,  and  the  interior  of  th(^ 
capsule  becomes  accessible.  The  lower  extremity  of  the 
femur  is  surrounded  by  a  circular  incision,  grasped  with 
forceps  at  the  inner  condyle,  and  divided  transversely 
with  a  saw. 

In  Hahu's  modification  the  transverse  incision  passes  above  the  pa- 
tella (Fig.  131). 

Kocher  recorameuds  a  lateral  hooked  incision  for  arthrotomy  and 
resection  of  the  knee-joint.  The  incision  begins  at  the  vastus  externus 
muscle,  a  hand's  breadth  above  the  patella,  two  fingers'  breadth  from 
whose  outer  border  it  passes  downward,  to  terminate  upon  the  inner  aspect 
of  the  tibia  below  its  spine.  The  articular  capsule  is  divided  on  its  outer 
aspect  and  the  patellar  ligament  removed  out  of  the  way  by  separation 
of  the  spine  of  the  tibia.  The  patella  with  its  ligament  is  made  so  mov- 
able that  it  can  be  reflected  inward.  Division  of  the  crucial  ligaments 
permits  a  satisfactory  view  of  the  joint  when  placed  in  a  position  of 
flexion.  Adequate  access  to  the  joint  is  had  also  for  the  performance  of 
resection  of  the  articular  elements. 

Resection  of  the  Ankle-joint. — Bilateral  Longitudinal  In- 
cision after  Langenbcch. — The  longitudinal  incisions  begin 
on  either  side,  a  hand's  breadth  above  the  malleoli,  and 
pass  along  the  tibia  and  fibula  beyond  their  lower  extremi- 
ties.    The  incisions  pass  through  skin  and  periosteum. 


212 


OPERATIVE  SURGERY. 


AVith  the  foot  lying  upon  its  inner  border,  the  fibula  is 
dissected  free  beneath  the  periosteum  ^vith  a  knife  or  a 
raspatory  on  its  outer  and  inner  aspeets,  and  is  divided  in 
a  linear  direction  above  the  malleoli  with  chisel  and  mallet 
or  with  the  chain-saw.  The  peripheral  fragment  of  the 
bone  is  reflected  outward  and  separated  from  its  attach- 
ments. In  an  analogous  manner  the  lower  extremity  of 
the  tibia  is  excised  through  the  internal  longitudinal  in- 


FiG.  131. — Hahn's  suprapatellar  incision  for  resection  of  the  knee-joint. 


cision.  By  the  removal  of  the  malleoli  a  view  can  be 
had  of  the  interior  of  the  joint,  and  the  trochlear  surface 
of  the  astragalus,  as  well  as  the  walls  of  the  cap.sule,  is 
rendered  accessible  for  further  operative  procedures. 

Lanofenbeck  has  obtained  the  most  admirable  results 
with  this  conservative  method  of  resection  following  gun- 
shot-injuries of  the  ankle-joint,  and  especially  transverse 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    213 

wounds  Avith  destruction  of  both  malleoli.  The  operation 
is  less  well  adapted  for  the  modern  j)roe('dure  of  arthrec- 
tomy,  as  the  lower  extremities  of  the  libula  and  tibia  are 
sacrificed,  at  any  rate,  and,  besides,  the  opportunity  for 
inspection  of  the  joint  afforded  through  the  incisions  is 
not  adequate  to  meet  the  needs  of  extirpation  of  the 
capsule. 

Konig^s  Bilateral  Longitudinal  Incision. — The  incision 
on  the  inner  aspect  begins  3  or  4  cm.  above  the  level  of 


Fig.  132. — Kesection  of  the  ankle-joint  by  Konig's  bilateral  longitudinal 

incision. 


the  articulation  upon  the  tibia,  somewhat  internal  to 
the  extensor  tendons,  and  it  opens  the  joint  close  to  the 
anterior  boundary  of  the  inner  malleolus.  It  passes  over 
the  body  and  neck  of  the  astragalus,  to  terminate  at  the 
inner  border  of  the  foot  at  a  point  corresponding  with  the 
tuberosity  of  the  scaphoid  bone.  The  outer  incision  runs 
parallel  with  the  inner,  along  the  anterior  surface  of  the 


214  OPERATIVE  SURGERY. 

tibia,  opens  the  joint  at  the  malleolus,  and  terminates  at 
the  level  of  the  astragaloscaphoid  articulation  (Fig.  132). 
The  anterior  bridge  of  skin,  which  contains  the  extensor 
tendons,  the  vessels,  and  the  nerves,  is  dissected  from  the 
subjacent  tissues,  the  insertion  of  the  capsule  being  at  the 
same  time  detached  transversely  from  the  trochlea  of  the  as- 
tragalus and  the  border  of  the  tibia,  and  if  necessary  the 
anterior  portion  of  the  synovial  membrane  is  excised.  By 
lifting  up  the  bridge-like  flap,  with  dorsal  flexion  of  the 
foot,  the  individual  portions  of  the  joint  may  be  made 
accessible  to  the  eye  and  to  instrumental  manipulation. 
The  removal  of  the  astragalus  is  readily  eflPected  through 
the  inner  incision,  when  the  articular  surface  of  the  tibia 
and  the  posterior  wall  of  the  capsule  become  visible. 

Reverdin-Kocher  3Iethod  of  Luxation  through  an  Ex- 
ternal Transverse  Arched  Incision. — The  incision  begins 
at  the  tendo  Achillis  about  a  hand's  breadth  above  the 
malleolus,  passing  downward,  surrounding  the  external 
malleolus,  and  terminates  on  the  outer  border  of  the  foot 
along  the  outer  margin  of  the  extensor  tendons  (Fig.  133). 
After  division  of  the  skin  and  exposure  of  the  external 
malleolus  the  accessory  ligaments  of  the  capsule  inserted 
in  this  situation  are  divided.  The  attachment  of  the 
capsule  is  freed,  with  displacement  of  the  extensor  ten- 
dons, and,  if  necessary,  division  of  the  peroneal  tendons 
upon  the  anterior  and  posterior  aspects  of  the  tibia,  when 
the  foot  is  flexed  upward  in  such  a  manner  over  the  in- 
ternal malleolus  that  its  inner  border  is  brought  in  contact 
with  the  inner  aspect  of  the  tibia  (Figs.  134  and  135). 
The  joint  is  thus  made  accessible  to  inspection,  and  neces- 
sarv  operative  procedures  upon  the  articular  extremities, 
as  well  as  upon  the  capsule,  may  be  undertaken. 

Resection  of  the  Foot  by  the  Method  of  Wladimiroff  and 
Mikulicz. — Indications  : 

(1)  Caries  of  the  foot  localized  in  the  calcaneum,  the 
astragalus,  and  the  astragalocrural  articulation. 

(2)  Extensive  loss  of  substance  al)out  the  heel. 

(3)  Injuries  of  the  heel,  especially  gunshot-wounds. 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    215 


Fig.  133. — Resection  of  the  ankle-joint  by  the  method  of  Reverdin- 
Kocher:  cutaneous  incision  ;  exposure  of  the  ankle-joint  from  its  outer 
aspect. 


Fig.  134. — First  stage  of  rotation  of  the  foot  at  the  ankle-joint  about  the 

inner  malleolus. 


Fig.  135. —Completed 
rotation  ;  the  lower 
extremities  of  the  tibia 
and  the  fibula,  as  well 
as  the  trochlea  of  the 
astrajralus,  are  com- 
pletely exposed. 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    217 

(4)  ^Falignant  tumors  about  the  heel  (osteosarcoma, 
melanosareonia)  (l^riins). 

(5)  Shortening  of  the  extremity,  following  luxations  of 
the  liip-joint  (Caselli) ;  after  resections  of  the  knee-joint 
(Rydygier). 

(6)  Paralytic  club-foot  (Bruns). 

The  parts  removed  in  the  resection  include  the  lower 
extremities  of  the  tibia  and  the  fibula,  the  astragalus,  the 
calcaneum,  and  a  portion  of  the  cuboid  and  scaphoid 
bones  in  conjunction  with  the  skin  of  the  heel.  The 
anterior  portion  of  the  foot  is  maintained  in  relation  with 
the  leg  by  means  of  a  dorsal  bridge  containing  the  ten- 
dons and  vessels. 

Mode  of  Procedure. — A  transverse  incision  is  made 
through  the  sole  of  the  foot  corresponding  to  the  extremi- 
ties of  Lisfranc's  line,  and  a  second  transverse  incision  is 
made  transversely  above  the  malleoli  on  the  posterior 
aspect  of  the  leg  ;  the  extremities  of  both  being  united  by 
additional  lateral  incisions  (Fig.  136).  The  astragalo- 
crural  joint  is  opened  from  the  dorsal  aspect  and  stretched 
widely,  and  the  bones  of  the  leg  are  divided  transversely 
above  the  malleoli.  The  root  of  the  foot  is  grasped  at 
the  trochlea  of  the  astragalus,  and  it  is  freed  close  to  the 
bone  from  the  dorsal  soft  parts,  with  maximum  dorsal 
flexion  of  the  foot.  In  accordance  with  the  extent  of 
tissue  to  be  removed  the  tarsus  is  sawed  through  in  the 
region  of  the  cuboid  and  scaphoid  bones,  or  further  to 
the  distal  (at  the  base  of  the  metatarsal  bones)  or  to  the 
proximal  side.  When  the  operation  is  performed  for 
orthopedic  reasons,  only  the  lower  extremities  of  the  tibia 
and  the  fibula  and  the  tuberosity  of  the  calcaneum  are 
removed,  together  with  the  trochlea  of  the  astragalus. 
Inasmuch  as  after  the  resection  has  been  effected  the 
sawed  surfaces  of  the  bones  of  the  leg  and  the  tarsus  are 
approximated  and  united  by  bone-suture,  there  results  an 
artificial  club-foot  to  such  a  degree  that  the  dorsum  of  the 
foot  lies  in  the  same  plane  as  the  anterior  aspect  of  the 
leg  (Figs.  137  and  138). 


218  OPERATIVE  SURGERY. 

In  performing  tihiocalcaneal  resection  by  the  method  of  Bruns,  the 
ankle-joint  is  opened  through  an  arched  dorsal  incision,  the  astragalus 
freed,  and  the  lower  extremities  of  the  tibia  and  the  fibula,  as  well  as 
the  upper  surface  of  the  calcaneum,  sawed  through  transversely,  when 
the  sawed  surfaces  are  nailed  together. 

Osteotomy. — Osteotomy  consists  in  linear  division  by 
bloody  means  of  the  long  bones.  Originally  performed 
through  an  open  wound,  the  operation  has  since  the  time 
of  Langenbeck  been  performed,  like  tenotomy,  through  a 
small  incision  in  the  skin,  in  a  measure  subcutaneously. 
The  division  of  the  bone  is  effected  with  the  aid  of  sculp- 
tor's chisels. 

The  extremity  is  placed  upon  a  board  or  upon  a  sand- 
bag, the  Esmarch  apparatus  is  applied,  and  the  operation 
of  osteotomy  is  undertaken.  A  short  incision  through  the 
soft  structures  penetrates  down  to  the  bone.  AVith  slight 
blows  of  the  mallet  the  chisel  is  driven  into  the  bone. 
After  it  has  penetrated  it  is  removed,  and  a  similar  pro- 
cess is  gone  through  in  a  neighboring  situation.  In  this 
manner  the  cortical  structure  of  the  bone  is  successively 
divided  transversely  throughout  almost  its  entire  circum- 
ference. The  remainder  is  fractured  by  forcible  bending, 
and  the  extremity,  after  the  cutaneous  wound  has  been 
properly  united,  is  fixed  in  an  appropriate  position  in  a 
plaster-of-Paris  dressing. 

In  cases  in  which  simple  linear  osteotomy  will  no  longer 
suffice,  wedge-shaped  excisions  are  undertaken  for  the 
correction  of  ankylosis,  or  curvatures  of  high  degree. 
The  base  of  the  wedge  corresponds  always  with  the  con- 
vexity of  the  curvature  to  be  corrected.  After  adequate 
exposure  of  the  bone  and  division  and  detachment  of  the 
periosteum,  the  wedge  is  removed  with  the  chisel  or  the 
saw,  when  the  correction  of  the  deformity  may  be  readily 
eifected. 

A  special  form  of  osteotomy  employed  for  the  correc- 
tion of  marked  arcuate  curvature  of  the  long  bones  con- 
sists in  longitudinal  division,  the  bone  being  divided  in  a 
direction  parallel  with  its  long  axis.     The  displacement 


RESECTIOSS  AT  JOiyTS  OF  THE  EXTREMITIES.    219 


Resection  of  the  Foot  by  the  Method  of  Wladimiroff- 

MlKULlCZ. 


Fig.  136. 
Cutaneous  incisions. 

Fig.  137. 
Configuration  of  the 
foot  after  resection  has 
been  effected.  The 
sawed  surfaces  of  the 
bones  of  the  leg,  as  well 
as  those  of  the  cuboid 
and  scaphoid  bones,  are 
exposed. 

Fig.  138. 

Appearance  of  the 

stump. 


Fig.  136. 


r 


-'% 


Fig.  137. 


Fig.  138. 


RESECTIONS  AT  JOINTS  OF  THE  EXTREMITIES.    221 

of  the  segments  of  bone  in  the  axis  of  the  part  renders 
possible  to  a  certain  degree  correction  of  deformity. 

Odcotomy  of  the  femur  at  the  upper  extremity  of  the  bone 
is  undertaken  in  cases  of  contracture  of  the  thigh,  if  the 
correction  of  the  faulty  position  is  attended  with  difficulty 
after  division  of  the  contractured  soft  parts.  Linear 
osteotomy  under  these  circumstances  is  undertaken  either 
at  the  neck  of  the  femur  (osteotomia  colli  femoris),  or  at  a 
point  between  the  two  trochanters  (osteotomia  intertro- 
chanterica).  For  the  exposure  of  the  upper  extremity  of 
the  femur  a  longitudinal  incision  over  the  trochanter  is 
made  upon  the  postero-external  aspect  of  the  joint.  In 
this  situation  the  neck  of  the  femur  can  be  exposed  for 
osteotomy,  as  well  as  a  deeper  portion  of  the  bone  after 
separation  of  the  muscular  attachments  to  the  greater 
trochanter. 

Supracondylar  osteotomy  of  the  femur  has  been  recom- 
mended by  Macewen  as  a  routine  procedure  in  the  treat- 
ment of  genu  valgum.  According  to  Mace  wen's  recom- 
mendation, the  short  cutaneous  incision  on  the  inner  aspect 
of  the  lower  extremity  of  the  femur  is  made  at  a  point 
corresponding  to  the  intersection  of  two  lines,  of  which 
one  passes  a  finger's  breadth  above  the  upper  border  of 
the  external  condyle,  and  the  other  in  the  longitudinal 
axis  of  the  bone  two  fingers'  breadth  in  advance  of  the 
tendon  of  the  adductor  magnus.  At  the  point  of  inter- 
section of  these  two  lines  a  short  longitudinal  incision  is 
made  down  to  the  bone,  the  chisel  introduced  through  the 
wound,  applied  transversely,  and  the  cortical  structure  of 
the  bone  successively  divided  throughout  two-thirds  of  its 
circumference.  The  remainder  of  the  bone  is  severed  by 
manual  means.  Supracondylar  osteotomy  of  the  femur 
may  also  be  undertaken  from  the  outer  side  of  the  bone 
in  a  corresponding  situation. 

Linear  osteotomy,  as  well  as  excision  of  wedge-shaped 
portions,  may  be  undertaken  upon  the  bones  of  the  leg 
for  the  correction  of  deformities  at  the  knee-joint,  or  of 
excessive  curvature.     The  tibia  is  exposed  at  its  upper 


222  OPERATIVE  SURGERY. 

extremity,  from  4  to  6  cm.  below  the  articular  line,  by 
means  of  a  transverse  incision  around  the  inner  circum- 
ference of  the  bone  (Kocher).  After  detachment  of  the 
periosteum  the  bone  is  divided  with  the  chisel  in  the 
direction  of  the  cutaneous  incision. 

Excision  of  a  Avedge-shaped  portion  of  the  tibia  may 
also  be  effected  through  the  same  incision. 


Tni:i'iiis'[NO.  223 


II.  OPERATIONS  ON  THE  HEAD  AND  NECK. 

Trephining". — Trcpliining  consists  in  resection  of  the 
l)ones  ol'tlic  skull  in  their  contimiity.  The  term  is  M|)])li('(l 
equally  to  the  excision  of  small  circular  segments  and  the 
establishment  of  a  penetrating  defect  in  the  skull,  to  the 
temporary  removal  of  a , portion  of  the  bone  in  conjunction 
with  the  periosteum  and  the  skin,  as  well  as  to  the  re- 
moval of  loose  depressed  splinters,  the  elevation  of  the 
indented  calvarium,  and  the  correction  of  irregularities 
in  wounds  following  injuries  of  the  skull. 

Indications : 

(1)  Injuries. — Open,  or  subcutaneous  fractures  of  the 
skull ;  if  the  bones  exhibit  depression  ;  if  local  or  general 
symptoms  referable  to  the  brain  are  present  (extravasation 
of  blood  in  cases  in  which  the  middle  meningeal  artery  is 
injured). 

(2)  Tumors  of  the  cranial  bones,  of  the  dura,  and  of  the 
brain. 

(3)  Cerebral  abscess. 

(4)  Epilepsy/  (for  the  extirpation  of  cortical  centers  or 
for  the  removal  of  cicatrices  and  foreign  bodies). 

(5)  Caries  and  necrosis  of  the  cranial  bones. 
Finally,  trephining  has  been  recommended  for  the  relief 

of  chronic  increase  of  intracranial  pressure,  and  in  cases 
of  progressive  paralysis  of  the  insane.^ 

In  general,  the  operation  is  performed  in  such  a  way 
that  after  division  of  the  scalp,  the  aponeurosis  of  the 
occipitofrontal  muscle,  and  the  pericranium,  a  suitable 
segment  of  bone  is  removed  with  the  crown  of  the  tre- 
phine, the  chisel  and  mallet,  or  the  circular  saw.  The 
exposed  dura  is  either  opened  with  a  crucial  incision  or  is 
reflected  back  as  a  flap,  and  after  the  operation  has  been 

^  In  insanity  of  traumatic  origin,  in  which  the  seat  of  initial  trouble  is 
made  manifest  by  a  scar,  a  persistent  headache,  or  muscular  iihcnonieiia 
of  a  local  character,  it  may  be  proper  to  trephine.  The  operation  is, 
however,  rarely  justifiable  in  insanitj^,  and  wiU  not  often  be  productive 
of  benefit. — Ed. 


224  OPERATIVE  SURGERY. 

finished  it  is  closed  with  catgiit-siitures.  The  deficiency 
in  the  bone  established  either  remains  open  or  it  is  closed. 
Under  the  condition  first  named,  the  skin  being  utilized  to 
cover  the  defect  in  the  bone,  the  opening  becomes  closed 
by  connective  tissue,  a  result  that  is  attended  with  certain 
disadvantao-es.  It  has  therefore  become  the  rule,  whenever 
the  nature  of  the  case  renders  it  permissible,  to  close  the 
trephine-opening  by  means  of  bone.  This  may  be  effected  : 

1.  By  reimplantation  of  the  piece  of  bone  trephined  ; 

2.  By  autoplasty  or  heteroplasty  ; 

3.  By  temporary  resection  of  the  cranial  bones,  em- 
ployed from  the  outset  as  a  substitute  for  typical  tre- 
phining. 

The  restored  button  of  bone  should  at  the  present  time, 
under  aseptic  conditions,  heal  in  place  in  all  cases  ;  but 
reimplantation  has  been  successfully  undertaken  by  Ph. 
v.   Walther. 

Autoplasty,  an  ingenious  procedure  devised  by  Kdnig, 
consists  in  the  transplantation  upon  the  defect  of  a  pedun- 
culated flap  consisting  of  skin,  periosteum*,  and  a  portion 
of  the  cortical  structure  separated  with  a  chisel.  The 
defect  resulting  from  the  formation  of  the  flap  is  covered 
with  a  pedunculated  cutaneous  flap  removed  from  the  ad- 
jacent region. 

Covering  in  the  defect  in  the  bone  with  foreign  bodies — 
metallic  plates,  bone,  celluloid  plates — is  designated  het- 
eroplasty} 

Steps  of  the  Opjeration  of  Trepkining. — A  linear,"  semi- 
circular, or  crucial  cutaneous  incision  is  made  down  to  the 
bone.^  The  periosteum  is  removed  with  a  raspatory.  If 
the  removal  of  the  bone  is  to  be  effected  with  a  circular 
saw,  or  with  mallet  and  chisel,  the  extent  of  tissue  to  be 

1  The  observations  of  Barker  indicate  that  after  a  piece  of  living  bone 
has  been  transplanted  it  undergoes  anemic  necrosis.  Xew,  living  tissue 
takes  its  place,  but  the  transplanted  piece  does  not  live.  In  fact,  it  seems 
probable  that  dead  bone  is  as  valuable  in  filling  a  defect  as  is  living 
bone. — Ed. 

2  In  most  cases,  a  U-shaped  flap,  the  base  of  which  is  the  dura,  gives 
the  best  exposure  and  is  followed  by  the  most  rapid  union. — Ed. 


TREPHTXTXG. 


225 


Temporary  Resection  of  thk  Ski'll. 


Fig.  139. — Form  of  the  cutaneuus  flap  :   the  }H»itii>ii  <>!'  huuc  to  be  leiiiuved 
has  been  outlined  with  the  chisel. 


Fig.  140. — The  flap  of  bone,  in  conjunction  with  the  skin,  has  been 
reflected  and  the  dura  is  exposed. 


15 


TREPIIiyiSG.  2T1 

removed  is  first  outlinetl,  and  the  incision  through  the 
bone  is  deepened  equally  at  all  parts.  In  the  groove  thus 
made  the  operator  can  determine  with  tlie  aid  of  the  probe 
when  the  vitreous  plate  has  been  passed.  As  soon  as  the 
plate  of  bone  is  freed  throughout  its  eireumference  it  is 
raised  with  an  elevator  and  removed  from  its  place.  The 
circular  saw  and  the  diisel  may  be  advantageously  used 
together,  the  boundary  of  the  part  to  be  removed  being 
outlined  with  the  saw,  and  the  groove  being  deepened 
down  to  the  dui*a  with  the  chisel. 

By  means  of  a  trephine  a  Ijutton  of  bone  is  removed 
from  the  skull  as  large  as  the  opening  in  the  crown  of  the 
instrument.  The  crown  is  evenly  and  firmly  applied  upon 
the  bone  with  its  teeth  while  the  head  is  fixed.  After  the 
teeth  of  the  instrument  have  entered  the  bone  the  pressure 
and  the  rotation  are  continued  in  even,  though  slighter, 
degree.  The  groove  made  by  the  saw  is  frequently  cleaned 
and  examined  as  to  its  depth.  As  soon  as  the  fragment 
of  bone  is  loosened  it  is  grasped  with  the  tirefond,  a  gim- 
let-like instrument,  and  is  removed.^  Bv  means  of  a 
special  knife,  known  as  the  lenticular,  it  was  customary  in 
the  past  to  smooth  the  margins  of  the  opening.  The  mode 
of  procedure  does  not  follow  this  typical  course  in  cases 
of  fracture  of  the  skull.  Completely  separated  splinters 
that  have  been  forced  into  the  brain  are  to  be  removed, 
depressed  portions  of  bone  are  to  be  raised,  and  sharp 
margins  are  to  be  cut  off,  etc.  For  elevating  and  re- 
moving fragments  of  bone  rongeur-forceps  are  employed  ; 
for  enlaro^incr  fissures  in  bones  the  chisel  and  mallet  are 
employed  exclusively. 

Temporary  resection  qftheshuU  (Wagner,  ^Volif,  Oilier) 
has  of  late  almost  entirely  replaced  the  classic  mode  of 
trephining.  AVagner  incises  the  skin  in  the  shape  of  a 
lyre  or  of  an  omega  fi?-shaped)  (Fig.  139),  the  incision 
passing  down  to  the  bone  at  all  points.     A  furrow  is  cut 

1  Instead  of  employing  a  special  instrument  to  lift  out  the  button,  the 
bit  of  bone  can  be  forced  out  by  means  of  a  periosteum-elevator  or  a  blunt 
dissector  used  as  a  lever. — Ed. 


228  OPERATIVE  SURGERY. 

into  the  bone  with  the  cireidar  saw  corresponding  with  the 
cutaneous  incision,  and  the  groove  is  gradually  deepened 
by  means  of  chisel  and  mallet  until  the  dura  is  reached. 
At  the  base,  corresponding  with  the  narrowest  portion  of 
the  flap,  the  bone  is  divided  with  a  single  stroke  upon  the 
chisel,  when  the  flap  of  integument,  periosteum,  and  bone 
can  be  reflected  (Fig.  140).  After  the  intracranial 
manipulation  has  been  completed  (opening  of  an  abscess, 
resection  of  a  cortical  center,  removal  of  a  foreion  bodv, 
ligation  of  the  middle  meningeal  artery,  etc.),  the  boue 
is  replaced  in  the  artificial  opening  and  the  cutaneous 
wound  is  closed  by  suture. 

To  facilitate  the  localization  of  the  anterior  and  posterior  branches  of 
the  middle  meningeal  artery  Steiner  has  suggested  the  following  ana- 
tomic guides  :  a  line  is  drawn  from  the  middle  of  the  glabella  to  the 
apex  of  the  mastoid  process.  Upon  the  middle  of  this  line  another,  verti- 
cal line  is  erected.  Where  the  latter  intersects  a  third  line  passing  hori- 
zontally through  the  glabella  the  crown  of  the  trephine  is  applied,  and 
on  removal  of  the  button  of  bone  the  trunk  of  the  anterior  branch  of 
the  middle  meningeal  artery  will  be  reached  (Fig.  141). 

At  the  point  where  a  vertical  line  passing  in  fi'ont  of  the  mastoid  pro- 
cess intersects  the  horizontal  line  already  spoken  of  a  trephine-opening 
"will  reach  the  posterior  branch  of  the  middle  meningeal  artery. 

Since  the  introduction  of  temporary  resection  of  the  skull  by  means  of 
the  chisel,  the  making  of  a  number  of  isolated  trephine-openings  for  the 
exposure  of  the  two  branches  of  the  middle  meningeal  artery  is  obviated. 
By  the  formation  of  a  flap  of  suitable  size,  with  its  base  above  the  malar 
bone  (Krause'sflap  for  intracranial  exposure  of  the  Gasserian  ganglion), 
it  has  become  possible  to  expose  the  branches  of  the  middle  meningeal 
artery  throughout  a  sufficient  extent  (Fig.  141).  The  length  and  width 
of  the  flap  spoken  of  are  about  6  cm. ;  the  former  measured  from  the  zygo- 
matic i^rocess,  the  latter  a  thumb's  breadth  external  to  the  margin  of  the 
orbit. 

The  upper  extremity  of  the  Rolandic  fissure  lies  in  an 
anteroposterior  plane,  1.2  cm.  behind  tlie  middle  of  a  line 
uniting  the  root  of  the  nose  with  the  occipital  protuber- 
ance.^ 

^  In  the  making  of  an  osteoplastic  flap  the  bone  can  be  sectioned  with 
great  neatness  and  considerable  rapidity  by  the  use  of  the  Gigli  wire-saw 
after  the  plan  of  Obalinski.  Such  a  saw  consists  of  rough  steel  wire  with 
a  loop  at  each  end.  The  handles  of  a  chain-saw  tit  the  loops.  Two  or 
more  small  trephine-openings  are  made,  the  dura  between  the  openings 
is  separated  from  the  skull,  a  piece  of  silk  is  carried  from  opening  to 
opening  by  means  of  a  probe,  the  saw  is  pulled  through  by  means  of  the 
silk,  the  handles  are  attached,  and  the  bone  is  sawed  from  within  out- 
ward.— Ed. 


RESECTWyS  OF  THE  J  A  WS. 


229 


Resections  of  the  Jaws. — Resection  of  the  Upper  Jaw. 
— Till'  ui)jK'r  jaw  is  iviuuvcil  partially  or  wholly  wluii  the 
seat  of  malignant  disease. 

Temporary  reHevtirm  of  the  iipjx?r  jaw  may  be  undertaken 
to  expose  the  naso])harynx  or  tlie  sphenomaxillary  fossa, 
the  temporal  fossa,  lor  i)iirposes  of  operative  intervention. 
The  body  of  the  upper  jaw  presents  three  processes  through 


5 


y 


Fig.  141. — Diao:rammatic  representation  of  the  method  of  finding  the 
upper  and  middle  branches  of  the  middle  meningeal  artery. 

which  it  articulates  with  neighboring  bones.  The  palatal 
process  unites  in  the  middle  line  with  a  similar  process  of 
the  bone  of  the  opposite  side.  The  frontal  or  nasal  pro- 
cess unites  the  upper  jaw  with  tlie  Irontal  bone,  and  the 
zygomatic  process  unites  it  with  the  malar  bone.  The 
posterior  surface  of  the  body  of  the  upper  jaw  is  united 
with   the  descending  wing  of  the  sphenoid  and  with  the 


230 


OPERATIVE  SURGERY. 


,r-r,4.--*^ 


pyramidal  process  of  the  palatine  bone.  These  processes 
must  all  be  severed  if  the  upper  jaw  is  to  be  separated 
from  its  attachments. 

Ste-ps  of  the  Operation. — The  head  of  the  patient  is 
placed  on  a  lower  level  than  the  trunk.  Preliminary 
tracheotomy  and  the  introduction  of  a  tampon-cannula 
are  not  necessary.  The  cutaneous  incision  (Weber)  is 
immediately  made  at  all  points  down  to  the  bone.  It 
begins  at  the  middle  of  the  upper  lip,  which  it  divides 
vertically ;  after  reaching  the  septum  it  surrounds  the 
nasal  ala  on  the  side  to  be  operated  upon  to  its  upper  ex- 
tremity ;  it  then  continues  vertically  upward  to  the  inter- 
nal canthus  of  the  eye,  and  thence  at  an  acute  angle  it 
passes  outward  in  a  curved  direction  along  the  lower  mar- 
gin of  the  orbit  to  end  at  the  external  canthus  of  the  eye 
(Fig.  142).  The  flap  thus  formed  from  the  soft  tissues 
of  the  cheek  is  dissected  from  the  upper  jaw  so  that  the 
canine  fossa,  as  well  as  the  malar  process,  is  exposed. 
The  inferior  tarso-orbital  meml:)rane  Ls  Jncised  alonsf  the 
infra-orbital 


TEeentir^coiSenS~(3'^ffi 

the  floor  of  the  orl)it,  from  which  the  chain-saw  or  the 
^wire;;^sa3vjsj)^  process  through  the 

infra-orbital  fissure  (Fig.  143)^iKniie  process  is  thus 
divided.  The  connection  between  the  nasal  process  of 
^thejjipperjaw  and  the  frontal  bone  is  divided  transversely 
with  the  chisel.  The  cfiv^ision  of  the  palate  and  of  the 
alveolar  process  must  yet  be  effected.  To  this  end  the 
mucous:j2£XiS5tea^^  of  the^  palate  js  incised  at  the 

alve()lain2I2£S^5§--2i3il-d£t^^^  ^^^^  bone  to  the  median 

7)fTn(r~arcli  of  the  palate.  The  chain-saw  is  intro- 
duced througli  the  pyriform  aperture,  and  brought  into 
the  moutli  at  the  junction  of  the  hard  and  the  soft  ])alate. 
Before  the  palatal  plate  is  sawed  through  the  middle  in- 
cisor tooth  of  the  corresponding  side  should  be  removed. 
The  jaw  is  now  attached  posteriorly  only  to  the  pterygoid 
process  and  the  pyramidal  process  of  the  palate  bone,  and 
above  to  the  ethmoid  bone.     It  is  freed  from  these  con- 


RESECTIONS  OF  THE  J  A  WS. 


231 


nortioiis,  the  alvcolnr  process  l)CMn<^  tj^raspcd  witli  Lani^on- 
Ixrk's  bone-foircps  and  irniovcd  with  slightly  rocking 
movements. 

In  the  large  wound  exposed  thQ_j^inMijxulJiifVa^C)i^ 
artery  must  l)c  cauulit  and   liii'atcd.     The  marjjfiiis  of  the 
cutaneous  wound  are  accurately  approximated  and  united 


Fig.  142. — Incisions  for  resection    if    tlic    upper  jaw:  a,   by   Weber's 
method  ;  b,  by  Velpeau's  method. 

by  suture.  If  it  has  been  possi])le  to  preserve  the  mucous 
covering  of  the  hard  palate,  this  is  united  to  the  mucous 
membrane  of  the  cheek  after  the  jaw  has  been  completely 
extirpated.  The  wound-cavity  is  in  all  cases  tamponed 
with  gauze.  If  the  cavity  is  separated  from  that  of  the 
UKHith  by  the  preservation  of  the  mucous  covering  of  the 
palate,  the  ends  of'  the  gauze  arebrough^mit  oft^^ 


^ 


232 


OPERATIVE  SURGERY. 


The  various  method.-  of  resection  of  the  upper  jaw  dif- 
fer from  oue  another  only  in  the  form  of  the  cutaneous 
incision,  the  procedure  up<jn  the  bone  l^eing  always  the 
same.  Among  various  forms  of  cutaneous  incision  may 
be  mentioned  Diellenbach's  median  incision,  a  vertical  in- 
cision from  the  root  of  the  nose^  over  the  roof  of  the  nose, 


Fig.  143.— Tlie  anterior  surface  of  the  upper  jaw  exposed  for  resection : 

the  maxillary  processes  are  already  divided. 

through  the  middle  of  the  upper  lip,  passing  down  to  the 
bone  and  dividing  the  cartilage  of  the  nose  and  the  upper 
lip.  From  the  upper  extremity  of  this  incision  a  second, 
short  incision  passes  to  the  inner  canthus  of  the  eye  (Fig. 
144).  Yelpeau  divides  the  cheek  in  the  form  of  an  arch 
from  the  angle  of  the  mouth  (Fig.  142,  b).     Malgaigne 


hesections  of  the  jaws. 


233 


combines  with  Velpeau's  iiK'i.si«ni  iiR-diaii  division  of  the 
upjKT  lip.  The  incisions  slionkl  atlbnl  convenient  access 
to  the  jaw,  willi  conservation  of  the  nerves,  the  vessels, 
and  of  Stenon's  duct,  and,  finally,  they  should  yield  favor- 


FiG.  144.— Incision  for  resection  of  the  upper  jaw  by  the  method  of 

Dieffenbach. 

able  cosmetic  results.     All  of  these  requirements  are  best 
met  by  AVeber's  incision. 

Temporary  resection  of  the  upper  jaw  (Langenbeck^s)  is 
made  through  a  tongue-shaped  flap  whose  base  corre- 
sponds with  a  line  uniting  the  root  of  the  nose  and  the 
lower  extremity  of  the  nasal  ala  of  the  same  side.  The 
flap   extends   externally    beyond   the   maxillary  process. 


234  OPERATIVE  SURGERY. 

The  following  structures  are  divided  :  the  upper  jaw  hori- 
zontally above  the  alveolar  process,  from  the  upper  inci- 
sion the  frontal  process  of  the  upper  jaw,  the  lachrymal 
bone,  the  floor  of  the  orbit  transversely  into  the  inferior 
orbital  fissure,  and  further  from  this  fissure  the  frontal 
process  of  the  malar  bone  and  transversely  the  makir 
arch.  The  upper  jaw  may  noAv  be  removed  in  conjunc- 
tion with  the  overlying  skin  and  be  reflected  upon  the 
nose. 

Resection  of  the  Lower  Jaw. — Upon  either  side  of  the 
body  of  the  lower  jaw  there  passes  upward  a  ramus  which 
articulates  through  its  upper  extremity  a\  ith  the  glenoid 
cavity  of  the  temporal  bone.  A  second  process  arising 
from  the  upper  extremity  of  the  ramus  is  the  coronoid, 
which  serves  for  the  attachment  of  the  tendon  of  the 
temporal  muscle.  The  external  surface  of  the  ramus  of 
the  lower  jaw  is  covered  by  the  masseter  muscle,  the  inner 
by  the  internal  pterygoid.  Both  of  these  muscles  are 
attached  at  the  angle  of  the  jaw.  The  entrance  into  the 
inferior  dental  canal  is  marked  upon  the  inner  aspect  of 
the  ramus  of  the  lower  jaw  by  a  bony  process.  A  de- 
pression passing  from  this  opening  on  the  inner  aspect  of 
the  jaw  obliquely  forward  and  downward  to  the  chin 
serves  for  the  attachment  of  the  mylohyoid  muscle. 

Usually  resection  of  only  one-half  the  lower  jaw  is 
necessary.  To  this  end  the  bone  is  divided  with  the  saw 
vertically  in  the  middle  line,  its  body  denuded  upon  its 
outer  and  inner  aspects,  and,  after  division  of  the  tendon 
of  the  temporal  muscle,  freed  at  its  articulation  with  tlie 
temporal  bone.  In  performing  total  resection  of  the 
lower  jaw  the  bone  is  likewise  first  divided  in  the  median 
line,  when  the  two  halves  are  separately  detached.  Tu- 
mors, as  well  as  necrosis,  furnish  the  indication  for  the 
performance  of  resection  of  the  lower  jaw. 

Steps  of  the  Operation. — The  patient  is  placed  upon  the 
table  with  the  upper  portion  of  the  body  elevated.  A 
cutaneous  incision  is  made  vertically  tlirough  the  middle 
of  the  lower  lip  down  to  the  chin,  and  from  here  at  an 


RESECTIONS  OF  THE  JAWS. 


235 


BKSKCTIONS  OF  TlIK  JA  ]VS. 


237 


EESECTIONS  OF  THE  J  A  WS.  239 

<)l)li(]ue  aii<i;le  it  is  directed  outward  in  the  line  of  the 
border  of  the  lower  jaw  to  its  anole.  The  incision  at  all 
points  penetrates  to  the  bone.  The  soft  parts  are  dis- 
sected from  the  external  surface  of  the  bone,  and  the 
mucous  membrane  of  the  cheek  is  incised  alonof  the 
alveolar  process  of  the  jaw  at  the  point  where  the  Hap  is 
to  be  reflected.  Through  the  cutaneous  incision  the  soft 
parts  are  to  be  freed  aliw  from  the  posterior  surface  of  the 
body  of  the  jaw.  After  division  of  the  mylohyoid  mus- 
cle the  mucous  membrane  is  incised  and  the  buccal  cavity 
is  opened.  From  the  inner  side  of  the  chin  the  origin  of 
the  genioglossus  and  the  geniohyoid  muscles  of  the  corre- 
sponding side  are  freed  with  the  knife  close  to  the  bone. 
After  extraction  of  the  inner  incisor  tooth  the  chin-saw 
or  the  wire-saw  may  be  passed  around  the  exposed  bone, 
and  the  division  is  to  be  effected  near  the  middle  line  in  a 
vertical  direction  (Fig.  145).  The  operator  grasps  the 
denuded  half  of  the  jaw  and  while  he  dislocates  the  bone 
in  abduction  divides  with  scissors  the  attachments  of  the 
masseter  and  pterygoid  muscles  at  the  angle  of  the  jaw. 
It  is  now  an  easy  matter  to  detach  by  blunt  dissection  the 
soft  parts  on  the  inner  and  outer  sides  of  the  ramus  of 
the  jaw.  AVhile  the  abducted  half  of  the  bone  is  rotated 
outward,  the  operator  divides  with  scissors  the  vessels 
and  nerves  that  enter  the  inferior  dental  canal,  as  well  as 
the  external  pterygoid  muscle  at  its  attachment  to  the 
articular  process  (Fig.  146).  After  the  tendon  of  the 
temporal  muscle  also  has  been  divided,  and  after  the  head 
of  the  lower  jaw  is  forced  out  of  the  glenoid  fossa,  the 
capsule  of  the  joint  is  detached  from  the  lower  jaw,  when 
the  bone  is  freed  from  all  its  attachments.  The  mucous 
membrane  of  the  cheek  is  united  by  suture  with  that  of 
the  floor  of  the  mouth,  and  the  wound  in  the  skin  also  is 
closed  by  suture. 

Temporary  Resection  of  the  Lower  Jaw. — Simple  divis- 
ion of  the  body  of  the  lower  jaw  is  undertaken  Avhen  it  is 
desired  to  render  accessible  the  floor  of  the  mouth,  the 
palatine  arch,  the  tongue,  and  the  base  of  the  brain  (re- 


240  OPERATIVE  SURGERY. 

section  of  the  third  division  of  the  trigeminns  bv  the 
operation  of  Mikulicz  for  purposes  of  surgical  interven- 
tion). The  division  is  made  either  in  the  middle  line 
through  the  chin  (Sedillot),  or  laterally  (Langenbeck). 
The  bone  is  sawed  through  or  is  divided  with  the  chisel 
either  in  a  linear  manner  or  in  the  form  of  a  step. 

Mode  of  Operation. — The  lower  lip  is  divided  in  the 
median  line  to  a  point  beloAV  the  chin.  From  the  lower 
extremity  of  the  incision  a  sharp-pointed  knife  is  passed 
ah)ng  the  posterior  surface  of  the  bone  and  brought  out 
at  the  frenum  of  the  tongue.  After  extraction  of  the 
middle  incisor  tooth  a  chain-saw  or  a  wire-saw  is  passed 
around  the  bone,  which  is  divided  in  a  linear  direction 
parallel  with  the  cutaneous  incision.  By  means  of  tenac- 
ula  the  cut  surfaces  of  the  bone  are  separated  widely, 
when  the  structures  of  the  floor  of  the  mouth,  the  sub- 
lingual gland,  and  the  tongue  itself  are  rendered  suf- 
ficiently accessible  (Fig.  147). 

The  posterior  portion  of  the  tongue,  the  palatoglossal 
arch,  the  pillars  of  the  fliuces,  and  the  wall  of  the  pharynx 
are  better  reached  through  lateral  temporary  division  of 
tlie  ramus  of  the  jaw,  as  recommended  by  Langenbeck 
(Plate  12).  The  cutaneous  incision  passes  vertically 
downward  from  the  angle  of  the  mouth  to  the  level  of 
the  larynx.  The  general  course  of  the  operation  corre- 
s]>onds  with  that  of  median  division.  In  both  instances, 
after  completion  of  the  operation,  the  divided  halves  of 
the  jaw  are  reunited  with  metallic  sutures.  The  cuta- 
neous wound  is  closed  with  knotted  sutures. 

Reseetion  of  the  Lower  Jaw  in  its  Continuity. — For  the 
removal  of  portions  of  the  lower  jaw  in  its  continuity  the 
cutaneous  incision  is  made  down  to  the  bone  at  its  mar- 
gin. The  soft  tissues  are  detached  from  the  outer  and 
inner  surfaces  of  the  jaw,  until  the  mucous  membrane  of 
the  lips,  as  well  as  that  of  the  floor  of  the  mouth,  is 
divided  close  to  the  bone.  At  the  two  points  through 
which  the  jaw  is  to  be  salved  a  tooth  is  withdra^vn,  and 
the  segment  of  bone  of  determined  size  is  removed  with 


RESECTIONS  OF  THE  J  A  WS 


241 


Fig.  147. — Median  temporary  division  of  the  lower  jaw  by  the  method 

of  Sedillot. 


16 


OPERA  no Xa   ox   rilK  TOXGUE.  243 

the  chain-saw.  In  siniihir  manner  the  middle  portion  of 
the  jaw  is  removed.  In  addition  to  the  incision  at  the 
margin  of  the  hone,  it  is  recomnR-ndc*!  that  tlie  lower 
lip  in  this  sitnation  he  divided  vertically  in  the  middle 
line  in  such  a  manner  that  an  incision  of  the  foUowinur 
form  results  :  I  .  Alter  resection  of  the  middle  portion 
the  stumps  of  the  genioglossus  muscles,  separated  from 
the  chin,  must  be  fixed -in  the  cntaneous  wound  by  sutnre, 
so  that  the  tongue  thus  deprived  of  its  attachment  to  the 
chin  does  not  fall  backward,  a  contingency  not  unattended 
with  danger. 

Operations  on  the  Tongue. — Extirpation  of  tumors 
of  the  tongue  are  atypical  })rocedures  that  are  not  carried 
ont  according  to  generally  applicable  rules.  It  is  of  the 
greatest  importance  that  the  removal  of  the  tumor  be 
effected  through  healthy  tissue,  and  that  the  wound-tlefect 
be  so  made  that  union  through  suture  or  closure  of  the 
wound  with  healthy  tongue-substance  is  possible.  The 
preliminary  operations  performed  for  the  pui-pose  of 
facilitating  total  extirpation  of  the  tongue  and  rendering 
the  floor  of  the  mouth  more  convenient  of  access  have 
already  been  considered  in  part  (temporary  resection  of 
the  lower  jaw). 

In  performing  operations  upon  the  tongue  the  patient 
is  placed  upon  the  table  with  the  upper  part  of  the  body 
elevated.  The  neck  is  stretched  and  the  head  is  fixed  in 
this  position.  The  mouth  is  held  open  with  a  suitable 
speculum  or  gag.  The  tongue  is  grasped  with  a  strong  silk 
ligature  passed  through  its  structure  and  drawn  forward. 

Circumscribed  tumors  at  the  margin  of  the  tongue  are 
excised  in  the  form  of  a  wedge  through  the  mouth  from 
healthy  tissue  with  the  scalpel  or  with  scissors.  The 
wound  can  be  closed  by  linear  approximation  through 
deep  and  superficial  sutures. 

In  advance  of  extirpation  of  half  or  the  whole  of  the 
tongue  ligation  of  the  lingual  artery  upon  one  or  both 
sides  is  undertaken  to  prevent  hemorrhage. 

If  the  extirpation  is  to  be  effected  through  the  poste- 


244 


OPERATIVE  SURGERY. 


Plate  12.— Lateral  Temporary  Division  of  the  Ramus  of  the 
Jaw  by  the  Method  of  Langenbeck. 

The  wound  is  made  to  gape  by  separation  of  the  segments  of  the  jaw  : 
M,  sawed  surfaces  of  the  ramus  of  the  jaw;  Oh,  hyoid  bone;  Bv,  digastric 
muscle,  with  its  tendon  divided  ;  3Ih,  mylohyoid  muscle ;  Hg,  hyoglossus 
muscle ;  H,  hypoglossal  nerve ;  L,  lingual  nerve ;  Sni,  submaxillary 
gland ;  SI,  sublingual  gland. 

rior  portion  of  the  tongue,  or  if  together  with  the  whole 
tongue  the  floor  of  the  mouth  and  the  sublingual  glands 
are  also  to  be  removed,  the  field  of  operation  is  rendered 
more  conveniently  accessible  by  preliminary  procedures. 
These  preliminary  operations  consist  in  : 


Fig.  148. — Incision  for  extirpation  of  the  tongue  by  the  method  of 

Kocher. 

1.  Division  of  the  cheek  from  the  angle  of  the  jaw ; 

2.  Submental  incision  (Regnoli-Billroth) ; 

3.  Temporary  division  of  the  lower  jaw  : 
(a)  In  the  middle  line  (Sedillot-Syme)  ; 

(6)  Through  the  ramus  of  the  jaw  at  a  point  cor- 
responding with  the  first  molar  tooth  (B.  v. 
Langenbeck). 


Tal. 


) 


\ 


■s. 

\ 


Luh.  .A/is!  h  Reichhold.  Mtindu 


OPERATIONS  ON  THE  TONGUE. 


245 


Fig.  149. — Submental  exposure  of  the  tongue  by  the  method  of  Billroth. 


OPERATIONS  ON  THE  TONGUE. 


247 


Wedge-shaped  Incision  of  the  Lower  Lip.    Linear 

Union. 


^ 


Fig.  150.— Showing  the  defect  in  the  soft  parts. 


/ 


f  IQ.  151.— Showing  the  defect  united  by  linear  suture. 


OPERATIONS  ON  THE  TONGUE. 


249 


Cheiloplasty  (Dieffenbach). 


Fig.  152.— Triaugular  detect  in  the  lower  lip  with  contiguous 
rhomboid  flaps. 


Fig.  153. — The  flaps  approximated  by  displacement  toward   the 
middle  line :  suture. 


OPERATIONS  ON  THE  TONGUE.  251 

Division  of  the  cheek  in  a  horizontal  direction  from  the 
angle  of  tlic  inoiitli  renders  tlie  operation  more  convenient, 
inasmuch  as  tlie  Held  of  operation  is  made  roomier,  and  it 
can  also  be  better  illuminated.  After  the  operation  on 
the  tongue  has  been  completed  the  incision  in  the  cheek 
can  be  united  by  suture. 

Suh)ncntal  removal  of  the  tongue^  first  performed  by 
Regnoli  of  Pisa,  is  effected  through  a  semilunar  incision 
made  upon  the  neck  along  the  ramus  of  the  lower  jaw. 
Regnoli  conjoined  with  this  arched  incision  a  second, 
vertical  incision  passing  from  the  chin  to  the  middle  of 
the  hyoid  bone.  Billroth  made  only  the  simple  arched 
incision.  Access  is  gained  to  the  inner  side  of  the  ramus 
of  the  jaw,  the  attachments  of  the  mylohyoid  muscle  are 
separated  laterally,  and  those  of  the  genioglossus,  genio- 
hyoid, and  digastric  muscles  in  the  middle,  and  the 
mucous  membrane  of  the  buccal  cavity  is  opened  through- 
out the  entire  extent  of  the  incision.  The  tip  of  the 
tongue  is  caught  with  a  thread  and  drawn  through  the 
wound.  By  these  means  the  structures  of  the  floor  of  the 
mouth,  as  well  as  the  tongue  down  to  its  base,  are  con- 
veniently accessible  for  operative  attack  (Fig.  149). 

Temporary  resection  of  the  lower  jaw  is  effected  in 
accordance  with  the  rules  laid  down  on  page  234.  The 
divided  portions  of  the  lower  jaw  are  held  apart  by  means 
of  sharp  hooks,  in  consequence  of  which  the  field  of 
operation  is  rendered  more  extensive.  The  division  of 
the  lower  jaw  may  be  linear,  or,  to  facilitate  approxima- 
tion in  suturing  the  bone,  it  may  be  made  in  steps. 

In  the  presence  of  extensive  disease  of  the  tongue 
Kocher  effects  extirpation  of  the  organ  from  the  base. 
He  first  performs  preliminary  tracheotomy.  The  cuta- 
neous incision  passes  from  the  mastoid  process  along  the 
anterior  border  of  the  sternomastoid  muscle  to  the  level 
of  the  hyoid  bone,  and  from  this  })oint,  in  the  furrow 
between  the  floor  of  the  mouth  and  the  neck,  forward,  to 
end  in  the  median  line  at  the  chin  (Fig.  148).  The  flap 
thus  outlined  is  reflected   back,  when,  after  ligation  of 


252  OPERATIVE  SURGERY. 

the  external  maxillary  and  lingual  arteries,  the  submaxil- 
lary glands  are  removed.  The  buccal  cavity  is  opened 
through  the  mylohyoid  muscle  and  the  raucous  membrane 
detached  from  the  lower  jaw.  The  tongue  must  yet  be 
separated  from  the  hyoid  bone,  after  which  the  whole 
organ  can  be  brought  forward  and  divided  through 
healthy  structure. 

Plastic  Operations. — Plastic  operations  include  those 
accessory  operations  by  means  of  which  existing  wound- 
defects  are  covered  with  integument,  as  well  as  such  pro- 
cedures as  are  intended  for  the  correction  of  congenital  or 
acquired  deformity.  In  the  first  category  belongs,  for 
instance,  the  formation  of  pedunculated  flaps  for  the 
closure  of  defects  left  by  wounds ;  in  the  latter,  operations 
for  harelip,  rhinoplasty,  blepharoplasty,  etc. 

In  covering  wound-defects  the  adjacent  skin  is  drawn 
over  either  directly  or  after  being  freed  by  incisions  and 
attached  in  place.  In  other  cases  flaps  taken  from  neigh- 
boring structures  must  be  separated  from  the  subjacent 
tissues,  and  either  displaced  laterally  or  rotated  about 
their  base,  in  order  that  they  may  be  brought  in  apposition 
with  the  defect,  and  fixed  in  place. 

A  triangular  defect  that  is  not  too  large  is  covered  directly  by  means 
of  deep  sutures  parallel  to  the  base,  and  linear  union  is  thus  eflFected. 
(Linear  union  after  wedge-shaped  excision  of  the  lower  lip  is  illustrated 
in  Figs.  150  and  151.)  If  the  defect  be  greater,  rhomboid  flaps  symmetri- 
cally situated  on  either  side  may  be  drawn  toward  the  middle  line  to 
cover  the  defect  (Diefienbach,  Figs,  15-2  and  153).  In  place  of  the  rhom- 
boid flap  an  arched  incision  passing  from  the  base  of  the  defect  on  either 
side  may  outline  a  portion  of  adjacent  skin,  which  is  brought  over  the 
defect  and  attached  in  place.  Quadrilateral  or  oval  defects  may  be  cov- 
ered by  one  or  two  symmetrically  formed  flaps  from  the  immediate 
neighborhood  (cheiloplasty  by  the  method  of  Bruns,or  by  thatof  Langeu- 
beck,  Figs.  154  and  155). 

The  flap  is  made  to  correspond  in  shape  with  that  of 
the  defect,  though  somewhat  larger.  These  methods,  in 
accordance  with  which  the  flaps  are  obtained  from  the 
immediate  neighborhood  of  the  defect,  stand  in  contra- 
distinction with  that  in  which  a  pedunculated  flap  belong- 
ing to  a  remote  portion  of  the  body  remains  attached  in 


PLASTIC  OPERATIOSS. 


253 


its  orifrinal  situation  thmuirli  tlic  pofliclc  until  the  flap  has 
healed  in  the  deteet  (rhinoplasty  by  means  of  a  flap  re- 
moved from  the  arm,  aceording  to  the  method  of  Tag- 
liacozzi). 

Another   nietlKwl  for  eovering  in  defieieneies  by  means 
of  skin  removed   from  remote  portions  of  the  body  con- 


r 


-^ 


^> 


Fig.  154.— Oval  defect  in  the  lower  lip :  outline  of  the  flap  (by  the 
method  of  Langenbeck). 

sists  in  the  formation  of  a  bridge-shaped  flap,  beneath 
which  the  part  to  be  covered  is  pu.<hed  and  fixed,  so  that 
wound-surface  comes  to  lie  in  apposition  with  wound- 
surface.  After  the  flap  has  united  it  is  detached  from  the 
subjacent  structures  by  transverse  division  of  its  extremi- 
ties. Finally,  flaps  completely  separated  from  their  at- 
tachments, that  are  not  pedunculated,  maybe  implanted  and 


254 


OPERATIVE  SURGERY. 


made  to  heal  upon  wound-surfaces  (Reverdin,  Thiersch). 
Thiersch  cuts  ^vith  a  l)road  knife  large  and  small  flaps  of 
epidermis  Avhich  are  placed  close  together  upon  a  fresh- 
ened wound-surface,  preferably  like  shingles  upon  a  roof. 
Krause  has  recently  applied  large  unpedunculated  flaps, 
removed  from  the  entire  thickness  of  the  skin,  upon  recent 
wound-surfaces  free  from  hemorrhage. 


Fig.  155. — The  detached  flap  is  placed  in  the  defect  and  there  sutured  : 
the  spur  is  united  with  the  lower  border;  the  free  border  of  the  lip  is 
formed  from  the  mucous  membrane  of  the  cheek  and  what  is  left  of  the 
lower  lip. 

Special  Forms  of  Plastic  Operations. — Rhinoplasty. — 
Plastic  restoration  of  the  nose.  Total  or  partial  rhino- 
plasty may  be  undertaken,  accordingly  as  total  or  partial 
restoration  of  the  nose  may  be  required. 

Formation  of  a  Nose  from  the  Skin  of  the  Forehead. — 
The  operation  consists  essentially  in  grafting  upon  the 
freshened  margins  of  the  defect  in  the  nose  an  approxi- 


PLASTIC  OPERATIONS. 


255 


mately  trian«i:iilar  Hap  fnmi  the  forclicad,  from  wliose  base 
the  nasjil  ahe  and  the  septum  arc  Ibrmcd.  Through  its 
apex  the  Hap  retains  its  eomieetioii  with  the  skin  at  the 
root  of  the  nose.  After  the  defect  has  been  freshened  the 
size  of  the  flaj)  to  l)e  formed  is  determined  by  measure- 
ment, a  tentative  flap  being  first  made  of  adhesive  plaster 
or  of  leather  and  fitted  to  the  deficiency.  After  the 
proper  shape  and  size  have  been  determined  the  model  is 
spread  upon  the  forehead  and  the  actual  flap  is  outlined 
about  this.  The  triangular  flap  thus  formed  lies  obliquely 
upon  the  forehead,  with  its  apex  directed  toward  the 
supra-orbital  margin.     The  one  side  of  the  frontal  flap  is 


Fig.  156. 


Fig.  157 


continuous  with  one  side  of  the  freshened  surface  of  the 
triangular  defect  in  the  nose.  The  flap,  together  with  the 
periosteum,  is  detached  from  the  subjacent  structures, 
rotated  at  an  angle  of  about  180°,  and  placed  over  the 
defect.  The  middle  segment  of  the  base  of  the  flap, 
folded  longitudinally  and  fixed  by  sutures,  forms  the  sep- 
tum. The  lateral  portions  of  the  flap  are  reflected  so  that 
wound-surfaces  are  brought  in  a])position  and  nasal  alae 
are  formed  on  either  side  (Figs.  15(3  and  157).  The  nose 
thus  formed  is  fitted  into  the  defect  and  fixed  in  ])lace  by 
sutures.  The  posterior  extremities  of  the  nasal  ahc  and 
the  septum  are  to  be  attached  to  the  freshened  surface  of 


256 


OPERATIVE  SURGERY. 


the  cheek  and  the  upper  lip,  when  the  lateral  margins  are 
to  be  united  with  the  lateral  portions  of  the  defect.  The 
defect  in  the  forehead  is  reduced  by  means  of  silk  sutures 
before  the  formation  of  the  nasal  alse  and  the  septum. 
The  defect  still  remaining  in  the  middle  is  permitted  to 
close  by  granulation,  or  it  is  covered  with  Thiersch  flaps. 
In  the  newly  formed  nasal  orifices  small  rubber  tubes  are 


Fig.  15S. — Total  rhinoplasty  from  the  skin  of  the  forehead. 

introduced  (Fig.  158).  The  disfiguring  fold  at  the  root 
of  the  nose  corresponding  to  the  point  of  reflection  of  the 
flap  can  be  removed  by  excision  at  a  second  sitting  after 
healing  has  taken  place. 

In  operating  for  the  correction  of  saddle-nose^  Konig 
utilizes  a  flap  made  from  the  soft  tissues  and  bone  of  the 
forehead  in  the  form  of  a  vertical  strip  Avith  its  base  at 
the  root  of  the  nose.     The  flap  thus  formed  is  freedj  re- 


PLASTIC  OPEUATluyS.  257 

Formation  of  a  Nasal  Ala  from  the  Skin  of  the  Cheek. 


\ 


1 -it-T.  i.,./. — iJeiect  aud  outlines  of  the  flap. 


Fig.  160. — The  flap  is  placed  iu  the  defect  and  there  sutured. 
17 


PLASTIC  OPERATIONS.  259 

fleeted  downward,  and  fastened  in  the  roof  of  the  mobile 
and  elevated  nose.  Over  this  flap,  iorniino-  the  sii])port 
of  the  nose,  tlie  organ  ])roper  is  iorined  from  the  skin  of 
the  forehead  in  the  usual  manner.* 

For  jxiriial  phistlc  operations  upon  the  nose  striet  rules 
cannot  be  fonnulated.  Huitable  procedures  will  have  to 
be  devised  ibr  the  individual  case  from  the  elements  for 
the  plastic  closure  of 'defects.  In  the  absence  of  the 
lateral  wall  of  the  nose  also  the  flap  to  cover  in  the  defect 
may  be  taken  from  the  forehead.  In  the  formation  of  a 
nasal  ala  a  pedunculated  flap  is  formed  from  the  dorsum  of 
the  nose,  and  from  the  opposite  side  of  the  nose,  or  from 
the  skin  of  the  cheek.  The  pedicle  of  the  flap  is  at  the 
upper  portion  of  the  back  of  the  nose  (Figs.  159  and  160). 
A  pedunculated  flap  formed  from  the  substance  of  the  upper 
lip  may,  by  rotation,  be  introduced  into  the  freshened 
defect  of  the  nasal  ala  and  there  be  fixed  by  suture.  To 
replace  an  absent  septum  the  tissues  may  be  advan- 
tageously obtained    from  the  upper  lip. 

Plastic  closure  of  defects  in  the  integument  of  the  cheek 
involving  its  entire  thickness  requires  special  operations. 
The  flap  engrafted  in  the  defect  must  be  covered  upon  its 
inner  surface  Avith  skin  or  mucous  membrane  to  prevent 
cicatricial  contraction.  Usually  cutaneous  flaps  are  so 
sutured  in  place  that  their  epidermal  aspect  is  directed 
toward  the  cavity  of  the  mouth.  Gersuny  forms  a  flap 
from  the  tissues  immediately  adjacent  to  the  defect,  whose 
pedicle  consists  only  of  subcutaneous  tissues.  Czerny 
employs  a  long  flap  made  from  the  integument  of  the 
neck,  which  is  folded  and  lies  in  the  defect  like  a  double 
flap.  The  flap  is  twice  as  long  as  the  defect  to  be  covered. 

Israel  forms  also  a  long  flap  from  the  integument  of  the 
neck,  whose  extremity  is  sutured  in  the  defect  in  such  a 
manner  that  the  cutaneous  surface  is  directed  toward  the 
buccal  cavity.     After  the  flap  has  healed  in  place  it  is 

^  In  saddle-nose  an  artificial  bridge  can  be  made  of  gold  or  platinum, 
and  this  bridge  is  slipped  in  place  through  an  incision  which  is  subse- 
quently sutured. — Ed. 


260  OPERATIVE  SURGERY. 

Operation  for  Harelip. 

Xelaton's  Method. 
Fig.  161. — Freshening. 

Fig.  162. — Wound  after  adjustment  of  the  lip. 
Fig.  163.— Suture. 

Malgaigne's  Method. 
Fig.  164. — Freshening. 

Fig.  165. — The  flap  on  either  side  is  dislocated  downward. 
Fig.  166.— Suture. 

Operation  for  Harelip. 
Mikault-Langenbeck's  Method. 

Fig.  167. — Freshening. 
Fig.  168.— Wound. 
Fig.  169.— Suture. 

Operation  for  Bilateral  Harelip. 

Fig.  170. — Freshening. 
Fig.  171.— Wound. 
Fig.  172. — Suture. 

severed  at  its  point  of  insertion  and  the  free  po.sterior  por- 
tion is  folded,  and,  Avith  Avound-surface  applied  to  wound- 
surface,  placed  upon  the  already  healed  portion  of  the  flap. 
The  flap  closing  in  the  defect  is  thus  doul)le,  Avith  its 
cutaneous  surfaces  directed  on  the  one  side  toA\ard  the 
mouth,  and  on  the  other  side  toAvard  the  exterior. 

Operation  for  Harelip. — Xelaton's  procedure,  intended 
for  the  correction  of  incomplete  harelip,  consists  in 
di\^ision  of  the  upper  lip  above  and  parallel  Avith  the 
defect.  The  margin  of  the  defect  is  clraAvn  downward  and 
the  rhombic  wound  is  united  in  a  linear  manner  at  right 
angles  to  the  transverse  fissure  of  the  mouth  (Figs.  161, 
162,  and  163).  Malgaigne  forms  a  flap  upon  either  side 
from  the  free  border  of  the  lip  bounding  the  defect  and 
removes  the  angle  of  the  defect.  The  flaps  are  deflected 
downward  and  nnited  AA^ith  one  another  (Fig.  164).  A 
modification  of  this  method  constitutes  the  operation  of 
Mirault-Langenbeck.  From  one  of  the  margins  of  the 
defect  a  Malgaigne  flap  is  formed  in  typical  manner.    The 


FLASTIC  OPERATIONS. 


261 


Fig.  161. 


Fig.  164. 


/ 


Fig.  162. 


Fig.  165. 


^ 


& 


Fig.  163. 


Fig.  166. 


PLASTIC  OPERATIONS. 


263 


Fig.  167. 


Fig.  170. 


Fig.  168. 


Fig.  171. 


Fig.  169. 


Fig.  172. 


PLASTIC  OPERATIONS.  265 

second  inaro;in  of  tlio  dofect  is  freshened  in  a  l)evelled 
manner  and  the  red  border  of  the  lip  is  removed  at  the 
angle  of  the  defect.  After  union  has  been  effected  the 
flap  constitutes  the  free  border  of  the  lip  (FigSo  167,  168, 
and  169). 

In  cases  of  bilateral  harelip  the  middle  segment,  as  well 
as  both  lateral  margins  of  the  defect,  must  be  freshened. 
A  Malgaigne  flap  is  fi)rmed  on  either  side  (Fig.  170), 
which  is  cut  through  at  its  apex.  The  flaps  are  displaced 
downward  and  united  with  one  another  below  the  middle 
segment.  The  margin  of  the  defect  on  either  side  is 
brought  in  apposition  with  the  corresponding  freshened 
edge  of  the  middle  segment,  with  Avhich  it  is  united  (Figs. 
171  and  172). 

If  the  fissure  in  the  lip  gapes  so  widely  that  its  margins  cannot  be 
brought  in  apposition,  free  incisions  are  made  through  the  nasal  alse 
to  give  mobility  to  the  margins  of  the  fissure  (Fig.  173). 


Fig.  173. — Freeing  incisions  when  the  fissure  in  the  lip  is  a  large  one. 

If  the  middle  segment  is  especially  prominent,  plastic  closure  of  the 
double  fissure  in  the  lip  is  to  be  effected  after  depression  of  the  inter- 
maxillary bone.  To  this  end  the  mucous  membrane  at  the  lower  free 
border  of  the  septum  is  divided  and  separated  from  the  vomer  on  either 
side.  The  vomer  is  divided  throughout  its  entire  height  with  a  single 
stroke  of  the  scissors,  when  the  intermaxillary  bone  can  be  pushed  into 
place  by  pressure  from  before  backward. 

Staphylorrhaphy  and  Uranoplasty. — StaphyloD'haphi/, 
plastic  closure  of  congenital  defects  of  the  soft  palate, 
consists  in  freshening  of  the  margins  of  the  defect  and 


266  OPERATIVE  SURGERY. 

their  union  by  suture.  The  operation  is  performed  with 
the  patient  either  in  the  upright  posture  or  with  the  head 
dependent.  The  margins  of  the  defect  are  grasped  indi- 
vidually with  forceps  and  the  freshening  is  effected  with 
a  small  sharp-pointed  knife,  and  union  is  established  by 
means  of  small,  strongly  curved  needles.  If  the  margins 
of  the  defect  can  be  brought  together  only  with  great 
tension,  it  is  recommended  that  freeing  incisions  be  made 
on  either  side  of  the  veil  of  the  palate. 

Plastic  closure  of  defects  of  the  hard  palate  (urano- 
plasty) is  effected  in  three  stages.  The  first  consists  in 
freshening  the  margins  of  the  defect  and  the  formation  of 
a  bridge-like  flap  on  either  side  in  such  a  manner  that 
an  incision  is  made  through  the  mucous  membrane  on  each 
side  down  to  the  bone,  parallel  with  the  margin  of  the 
defect,  at  the  alveolar  border  of  the  palate,  reaching  from 
the  last  molar  to  the  outer  incisor  tooth.  In  the  second 
stage  of  the  operation  the  flap  thus  outlined  is  rendered 
mobile,  the  mucous-periosteal  covering  of  the  palate  being 
separated  from  the  bone  by  means  of  a  small  raspatory 
introduced  through  the  outer  incision.  To  render  mobile 
the  soft  palate  its  attachment  to  the  palate  bone  is  freed 
by  means  of  a  knife  curved  on  the  flat,  so  that  the  flap  at 
all  points  can  be  moved  toward  the  middle  line  without 
tension.  The  last  stage  of  the  operation,  which  con- 
sists in  suture,  is  carried  out  in  the  middle  line  in  the 
same  Avay  as  in  staphylorrhaphy. 

To  avoid  undue  tension  upon  the  approximated  flaps  semilunar  lateral 
freeing  incisions  through  the  veil  of  the  palate  have  been  recommended 
(Dieffenbach).  Billroth  dispenses  with  the  incisions  through  the  velum, 
and  prefers  chiselling  the  median  plate  of  the  pterygoid  process  of  the 
sphenoid  bone,  by  displacement  of  which  inward  relief  of  tension  is 
effected.  Wolff  effects  sufficient  mobilization  of  the  soft  palate  by 
adequate  detachment  of  the  coverings  of  the  hard  palate,  so  that  acces- 
sory operations  are  unnecessary. 

Operations  on  Nerves. — If  in  cases  of  trigeminal 
neuralgia  conservative  methods  of  treatment  have  been 
unattended  with  success,  operativ^e  intervention  becomes 
allowable.       Simple    division    of  the    nerve    (iieurotomy) 


OPERATIONS  ON  NERVES.  267 

is  unjustifiable,  as  oxporlonro  lias  shown  that  the  trans- 
verse sections  ot"  the  divided  nerve  sliortly  reunite.  The 
exsection  of  a  portion  of  the  nerve  {iieurectomy)  is  more 
promising  in  this  connection,  although  the  nerve  is  re- 
generated after  a  somewhat  longer  time.  Large  segments 
of  nerves,  together  with  their  smallest  branches,  may  Ix' 
removed  by  means  of  the  procedure  of  Thiersch  (extrac- 
tion of  nerves,  ncurcxairesiii).  The  nerve  in  question  is 
exposed  in  a  given  situation,  grasped  transversely  with  a 
forceps-like  instrument,  and  removed  throughout  a  con- 
siderable extent  of  both  its  distal  and  its  proximal  course 
by  slowly  rotatory  movements  (a  half  rotation  in  the 
second,  Thiersch). 

First  (Ophthalmic)  Division  of  the  Fifth  Nerve. — The 
smallest  of  the  three  divisions  of  the  trigeminal  nerve 
enters  the  orbit  through  the  sphenoidal  fissure.  Of  the 
branches  of  the  ophthalmic,  only  tlie  frontal  nerve  is  of 
surgical  importance.  It  runs  along  the  roof  of  the  orbit, 
and  divides  into  two  branches  :  the  supratrochlear,  which 
leaves  the  orbit  above  the  pulley  of  the  superior  oblique 
muscle  to  supply  the  skin  of  the  upper  eyelid  and  the 
forehead  ;  and  the  supra-orbital,  which  passes  through  the 
supra-orbital  notch  to  the  forehead. 

To  expose  the  frontal  nerve  an  incision  is  made  below 
the  eyebrow  parallel  with  the  supra-orbital  margin,  dividing 
the  skin  and  the  tarso-orbital  fascia.  The  contents  of 
the  orbit  are  carefully  detached,  when  the  trunk  of  the 
nerve  becomes  visible  on  the  roof  of  the  cavity.  The 
branches  of  the  nerve  are  looked  for,  grasped  with  the 
forceps,  and  torn  out  individually  (Fig.  174). 

Second  (Superior  Maxillary)  Division  of  the  Fifth  Nerve. 
— The  supramaxillary  division  of  the  fifth  nerve  leaves 
the  cranial  cavity  through  the  foramen  rotundum,  enters 
the  sphenomaxillary  foramen,  and  passes  without  change 
of  course  through  the  infra-orbital  fissure  into  the  infra- 
orbital canal  on  the  floor  of  the  orbit,  leaving  the  latter 
through  the  infra-orl)ital  foramen,  to  break  u])  upon  the 
face  in  a  fan-shaped  distribution  into  its  various  branches. 


268 


OPERATIVE  SURGERY. 


The  infra-orbital  foramen  is  situated  in  the  canine  fossa 
about  0.5  era.  below  the  middle  of  the  infra-orbital  margin. 
To  expose  the  infra-orbital  nerve  at  its  point  of  exit  in 
the  canine  fossa  the  incision  is  made  about  0.5  cm.  below 
and  parallel  with  the  infra-orbital  margin  throughout  an 
extent  of  about  4  cm.  The  lower  margin  of  the  wound 
is  retracted  by  means  of  hooks.  The  incision  through 
the  elevator  muscles  of  the  upper  lip  passes  down  to  the 
bone,  and  the  periosteum  is  reflected  downward,  when  the 


Fig.  174. — Exposure  of  the  frontal  nerve. 

trunk  of  the  nerve,  as  it  escapes  from  the  infra-orbital 
foramen,  as  well  as  its  radiation  upon  the  face,  comes  into 
view.  After  division  of  the  inferior  tarso-orbital  mem- 
brane the  contents  of  the  orbit  are  raised  upward,  when 
the  infra -orbital  canal,  covered  bv  a  thin  lamella  of  bone 
on  the  floor  of  the  orbit,  is  exposed.  This  lamella  is 
removed  as  deeply  as  possible,  the  nerve  grasped,  and  its 
central  extremity  gradually  withdrawn  (Fig.  175).  The 
peripheral  portion  of  the  nerve  can  be  removed  to  its 
finest  branches  by  being  rolled  up  upon  Thiersch's  forceps. 


OPERA rroxs  ox  nerves.  269 

If  the  infra-orbital  nerve  is  to  be  exposed  at  the  base 
of  the  skull,  access  to  it  will  be  gained  ])y  tcnipornrv 
resection  of  the  malar  bone  (Losseu,  Braun).  An  incision 
through  tliC  integument  is  made  as  in  exposing  the  infra- 
orbital nerve,  and  it  is  extended  outward  over  the  malar 
])roniincnce.  The  malar  bone,  together  with  the  malar 
process  of  the  upi)er  jaw  and  the  zygomatic  ridge  of  the 
sphenoid  bone,  is  resected  in  such  a  manner  that  a  large 
portion  of  the  outer  wall  of  the  orbit  is  removed.  The 
malar  bone  is  drawn  outward,  if  it  is  divided  also  through 
its  temporal  process,  and  the  nerve  is  grasped  at  the 
foramen  rotunduni  and  extracted  with  Thiersch  forceps. 

Third  (Inferior  Maxillary)  Division  of  the  Fifth  Nerve. 
— The  third  division  of  the  trigeminal  nerve  leaves  the 
skull  through  the  foramen  ovale.  Of  the  upper  group  of 
its  branches  only  the  buccinator  nerve  is  subjected  to 
surgical  attack.  This  nerve  burrows  through  the  external 
pterygoid  muscle  and  passes  along  the  outer  surface  of  the 
buccinator  muscle  to  the  angle  of  the  mouth.  The  nerve 
is  at  times  the  seat  of  isolated  neuralgia.  Of  the  larger 
branches  of  the  inferior  maxillary  nerve,  the  inferior 
dental  and  the  lingual  are  of  surgical  importance.  The 
inferior  dental  nerve,  the  largest  branch  of  the  inferior 
maxillary,  passes  downward  between  the  internal  and 
external  j>terygoid  muscles.  On  the  inner  aspect  of  the 
ramus  of  the  lower  jaw  it  enters,  with  the  arteiy  of  the 
same  name,  into  the  dental  foramen  and  passes  through 
the  dental  canal,  to  make  its  exit  at  the  mental  foramen 
as  the  mental  nerve.  The  lingual  nerve  in  the  first  part 
of  its  course  passes  downward  with  the  dental  nerve.  At 
the  anterior  border  (^f  the  internal  pterygoid  muscle  it 
turns  forward,  and  passing  over  the  mylohyoid  muscle 
reaches  the  lateral  border  of  the  tongue. 

Extrdhuccal  Exposure  of  the  Buccinator  Xen'e  (E. 
Zuckerkandl). — A  cutaneous  incision  is  made  in  the  direc- 
tion of  a  line  passing  from  the  tragus  to  the  middle  of 
the  nasolabial  fold.  The  duct  of  Stenon  apj)ears  in  the 
wound  and  is  drawn  downward.     After  division  of  the 


270  OPERATIVE  SURGERY. 

masseter  fascia  the  buccal  pad  of  fat  comes  into  view,  and 
is  freed  from  its  attachments  and  removed.  In  the  wound 
there  are  now  visible  the  coronoid  process  of  the  lower 
jaw,  with  the  prominent  lower  portion  of  the  tendon  of 
the  temporal  muscle.  At  the  inner  border  of  this  tendon, 
surrounded  by  loose  cellular  tissue,  lies  the  trunk  of  the 
buccinator  nerve. 

The  inferior  dental  nerve  may  be  exposed  before  its 
entrance  into  the  dental  canal,  within  the  canal,  and  after 
its  exit  at  the  mental  foramen.  Prior  to  its  entrance  into 
the  canal,  at  the  lingula,  the  nerve  is  accessible  from 
without  (Sonnenburg-Lucker)  as  well  as  from  Avithin  the 
cavity  of  tlie  mouth  (Paravicini).  Sonnenburg  makes  an 
incision  around  the  angle  of  the  lower  jaw,  separates  the 
insertion  of  the  internal  pterygoid  muscle  from  the  bone, 
and  advances  along  the  inner  surface  of  the  ramus  of  the 
jaw  to  the  lingula,  where  the  nerve  is  gmsped  Avith  a 
blunt  hook,  brought  out  and  resected,  or  extracted  with 
forceps.  This  method  is  attended  with  difficulties  in  so 
far  as  it  is  necessary  to  operate  at  a  considerable  depth  ; 
even  operating  upon  the  dependent  head  simplifies  the 
procedure  only  in  inconsiderable  degree.  Paravicini  has 
recommended  exposure  of  the  nerve  from  the  buccal 
cavity  by  separation  of  the  internal  pterygoid  muscle 
from  the  inner  surface  of  the  ramus  of  the  jaw  at  the 
lingula. 

Exposure  of  the  Inferior  Dental  Nerve  within  the  Dental 
Canal. — The  nerve  is  most  conveniently  reached  by  chis- 
elling out  a  piece  of  the  outer  plate  of  the  bone  at  the 
point  of  junction  between  the  body  and  the  ramus,  and  in 
this  manner  exposing  the  dental  canal.  An  arch-shaped 
cutaneous  incision  is  made  at  tlie  angle  of  the  jaw. 
The  attachment  of  the  masseter  muscle  is  freed  and 
separated  from  the  bone  in  the  neighborhood  of  the 
angle  of  the  jaw  by  means  of  a  raspatory.  In  the  mid- 
dle of  a  line  uniting  the  angle  of  the  jaw  with  the  last 
molar  tooth  a  piece  of  bone  as  large  as  a  lentil  is  gouged 
out  of  the  outer  wall  of  the  jaw.     After  the  cortical 


OPERATIONS  ON  NERVES. 


271 


striK'turo  lias  Ixni  passed  profuse  arterial  heniurrliage 
from  the  injured  interior  dental  arterv  will  indieate  that 
the  eanal  has  been  oi)ened.  With  a  blunt  hook  the  nerve 
can  be  readily  raised  from  its  bed,  and  it  is  either  resected, 
or,  better,  it  is  extracted  with  forceps. 

The  lingual  nerve  is  most  readily  reached  from  tlie 
buccal  cavitv.  An  incision  is  made  uix>n  the  side  of  the 
tongue  at  the  point  of  i-eflection  of  the  mucous  membrane 
from  the   inner  side  of  the  lower  jaw  upon  the  tongue. 


Fig.  175. — Exposure  of  the  infra-orbital  nerve. 

The  large  nerve-trunk  lies  immediately  l)eneath  the 
mucous  membrane.  The  methods  of  Sonnenburg  and 
Paravicini  for  exposure  of  the  inferior  dental  nerve  also 
permit  access  to  the  lingual  nerve  in  its  upper  part. 

The  mental  nerve  can  be  made  accessible  at  its  point  of 
exit  from  the  lower  jaw,  from  either  within  or  without 
the  buccal  cavity.  Extrabuccal  exposure  is  accomplished 
by  means  of  a  cutaneous  incision  through  the  chin  at  the 
level  of,  and  several  centimeters  external  to,  the  incisor 


272  OPERATIVE  SURGERY. 

tooth  of  the  corresponding  side.  The  incision  reaches 
down  to  the  bone,  and  the  soft  parts  are  detached  from  the 
jaw,  when  the  nerve  can  be  seen  making  its  exit  as  a 
tense  cord  from  the  mental  foramen.  To  gain  access  to 
the  nerve  from  within  the  cavity  of  the  mouth  an  analo- 
gous procedure  is  followed.  The  incision  is  made  at  the 
point  of  reflection  of  the   mucous  membrane  from  the 


r 


./ 


Fig.  176. — Intrabuccal  exposure  of  the  mental  nerve. 

inner  surface  of  the  lower  lip  upon  the  lower  jaw^  (Fig. 
176). 

Operation  for  Exposure  of  the  Second  and  Third  Divis- 
ions of  the  Fifth  Nerve  at  the  Base  of  the  Skull  by  the 
Method  of  Krbnlein. — A  semicircular  flap,  with  its  con- 
vexity downward,  is  formed  from  the  tissues  of  the  cheek, 
its  base  corresponding  to  the  upper  boundary  of  the  zygo- 
matic arch.  The  cutaneous  flap  is  dissected  upward,  the 
temporal  fascia  divided  transversely  over  the  malar  bone, 
then  the  zygomatic  arch  sawed  through  in  advance  of  the 
articular  tubercle  and  through  the  body  of  the  bone  and, 
with  the   attachment  of  the  masseter  muscle,  reflected 


OVKHATIONS  ON  NERVES.  273 

downward.  Tlic  exposed  coroiioid  process  oi'  tlie  lower 
jaw  is  hroUeii  ihroiigli  and,  t()«!,'elljer  with  tlie  tendon  of 
the  temporal  niusi^h',  is  disphieed  n])\\ai<I.  'J'lie  third 
division  of  the  fifth  nerve  is  reached  by  i)assin<i,'  from  the 
npper  border  of  the  external  pterygoid  nuiscile,  toward 
the  base  of  the  skull,  just  behind  the  root  of  the  ptery- 
goid process,  where  the  foramen  rotnnduni  is  situated. 

To  reach  the  supramaxillarv  nerve  j^rogrcss  must  l)e 
made  forward  through*  the  wound  to  the  pterygopalatine 
fossa,  where  in  the  depth  of  the  depression  the  nerve  can 
be  grasped  \Nith  a  hook  just  after  its  exit  from  the  round 
canal  and  drawn  forward.  In  closing  the  wound  the 
detached  segments  of  bone  are  fixed  in  their  original 
situations  by  means  of  bone-sutures  and  the  margins  of 
the  cutaneous  wound  are   approximated. 

Exposure  of  the  Third  Division  of  the  Fifth  Nerve  at  the 
Base  of  the  Skull. — Refrobuccal  Method  of  KrmhiTi. — A 
cutaneous  incision  is  made  on  the  cheek  from  the  angle  of 
the  mouth  to  the  lobule  of  the  ear.  The  buccal  pad  of 
fat  is  lifted  out  of  its  bed  and  removed  completely,  when 
the  coronoid  process  is  divided  and  dislocated  upward. 
The  lingual  and  inferior  dental  nerves  are  exposed  and 
isolated  on  the  inner  aspect  of  the  ramus  of  the  lower  jaw 
and  followed  upward  to  the  base  of  the  brain,  while  the 
external  pterygoid  muscle  is  drawn  to  one  side.  Salzer 
forms  a  flap  from  the  tissues  of  the  cheek  and  the  tem- 
poral region,  with  its  base  downward  and  extending  a 
finger's  breadth  beyond  the  zygomatic  arch.  The  latter 
is  resected  and,  together  with  the  skin,  is  reflected  down- 
ward. The  temporal  muscle,  beginning  at  its  insertion, 
is  freed  from  the  bone.  Pro^ressino-  from  the  outer  sur- 
face  of  the  temporal  bone  toward  the  under  surface  of  the 
sphenoid  bone  the  foramen  ovale  is  reached,  where  the 
nerve  is  divided  with  a  tenotome  having  a  concave  edge. 
By  the  method  of  ^likulicz  access  to  the  trunk  of  the 
nerve  is  gained  by  temporary  resection  of  the  lower 
jaw  just  in  advance  of  the  insertion  of  the  masseter  mus- 
cle. The  cutaneous  incision  passes  from  the  mastoid  pro- 
is 


274  OPERATIVE  SURGERY. 

cess  along  the  sternomastoid  muscle  to  the  coniu  of  the 
hyoid  bone,  and  from  this  point  in  a  curved  direction  to 
the  anterior  border  of  the  masseter  muscle. 

Intracranial  Operations  on  the  Trigeminus. — Extirpation 
of  the  Gasserian  Ganglion  by  the  Jlethod  of  Krausc. — A 
uterus-shaped  flap  is  formed  from  the  structures  in  the 
temporal  region  (Fig.  141),  with  its  base  over  the  zygo- 
matic arch.  The  flap  is  6.5  cm.  long  and  its  base  meas- 
ures 3  or  3.5  cm.  Its  greatest  width  is  5  or  5.5  cm.  The 
incision  passes  down  to  the  bone.  The  cranium  is  divided 
Avith  the  circular  saw  or  with  chisel  and  mallet  in  the 
shape  and  size  of  the  cutaneous  flap  and  the  skin  with  the 
bone  attached  is  reflected  downward.  The  suro^eon  ad- 
vances  between  the  bony  floor  of  the  skull  and  the  dura 
in  the  middle  cerebral  fossa  to  the  foramen  spinosum, 
where  the  trunk  of  the  middle  meningeal  artery  is  ligated 
and  divided.  To  this  end  the  brain  enclosed  in  dura  must 
be  carefully  raised  upward  with  a  broad-bladed  spatula. 
After  extensive  separation  of  the  dura  from  the  bone  and 
elevation  of  the  brain  the  Gasserian  ganglion  comes  into 
view,  in  the  depth  of  the  middle  cerebral  fossa,  external 
to  the  dura.  The  ganglion  is  grasped  transversely  with 
Thiersch's  forceps  at  the  point  where  it  becomes  the  trunk 
of  the  trigeminus,  Avhen  the  second  and  third  divisions  of 
the  nerve  are  divided  in  the  intracranial  openings  of  the 
respective  canals.  The  first  division  of  the  nerve  will 
have  been  previously  divided  close  to  its  origin  from  the 
ganglion.  By  rotation  of  the  forceps  the  ganglion,  to- 
gether with  a  proximal  portion  of  the  trigeminus  trunk, 
will  be  extracted. 

Operations  on  the  Air-passages. — The  air-passages 
may  be  opened  through  the  larynx  (larynf/otomy),  or 
through  the  trachea  (tracheotomy).  The  incisions  for 
opening  the  respiratory  tract  are  longitudinal,  and  are 
made  on  the  anterior  aspect  of  tlie  neck  in  the  middle 
line.  The  upper  and  lower  hyoid  muscles,  which  cover 
the  respiratory  tract,  are  arranged  symmetrically  and 
meet  in  the  middle  line  of  the  neck.     Between  the  inner 


OriUlATIONS  ON  THE  AIR- PASSAGES.  275 

borders  of  these  muscles  (white  line  of  the  neck)  access 
iiKiy  he  «i'aine(l  to  the  larvnx  ov  the  trachea  hy  merely 
])assiiig  thruugh  the  layers  of  fascia  and  the  connective- 
tissue  space. 

Opening  of  the  Larynx  (Laryngotomy). — The  situation 
of  the  cart ila«2,i nous  constituents  of  the  larynx  can  be  ac- 
curately determined  from  the  surface  of  the  neck  by  pal- 
pation. The  laryngeal  prominence,  the  edge  formed  by 
the  approximation  of  the  lateral  halves  of  the  thyroid  car- 
tilage, the  arch  of  the  cricoid  cartilage,  are  accessible  to 
palpation,  as  well  as  the  cricothyroid  ligament,  which  ap- 
pears as  a  less  resistant  area  between  the  thyroid  and  cri- 
coid cartilages.  The  larynx  is  opened  in  the  middle  line 
either  through  the  thyroid  cartilage  (^/<Y/ro^Oii/i^)  or  through 
the  cricothyroid  ligament  (crlcothyrotomy) ;  finally,  the 
larynx  may  be  divided  by  a  median  incision  throughout 
its  entire  length  down  to  the  first  tracheal  ring  (laryru/o- 
fissurc).  Thyrotomy  or  la ryngo fissure  is  always  preceded 
by  tracheotomy  and  the  introduction  of  a  tracheal  cannula. 

Thyrotomy  is  undertaken : 

(1)  In  the  presence  of  foreign  bodies  in  the  larynx 
which  have  become  impacted  and  cannot  be  removed  by 
endolaryngeal  procedures ; 

(2)  In  the  presence  of  cicatricial  narrow^ing  of  the 
larynx  ; 

(3)  In  the  presence  of  tumors  of  the  larynx ; 

(4)  As  a  preliminary  operation  in  the  performance  of 
total  or  unilateral  extirpation  of  the  larynx. 

Laryngofissure  may  be  necessary  in  the  extirpation  of 
tumors  when  for  their  complete  removal  freer  access  to 
the  interior  of  the  larynx  is  required. 

In  the  performance  of  thyrotomy  or  larynr/ojissure  the 
patient  is  placed  in  the  dorsal  decubitus,  with  the  upper 
portion  of  the  body  elevated,  and  the  cervical  portion  of 
the  spinal  column  extended.  The  incision  is  made  accu- 
rately in  the  middle  line  from  the  hyoid  bone  to  the  cri- 
coid cartilage.  The  cervical  fascia  is  divided,  the  sterno- 
hyoid muscles  are  separated,  and  the  thyroid  cartilage  is 


276  OPERATIVE  SURGERY. 

Plate  13. 

The  thyrohyoid  membrane,  the  thyroid  cartilage,  the  cricothyroid 
membrane,  and  the  cricoid  cartilage  are  divided  in  the  middle  line. 

The  lateral  halves  of  the  thyroid  cartilage  are  held  apart  by  tenacula  : 
the  interior  of  the  larynx,  the  arytenoid  cartilages,  the  ventricular  bands, 
and  the  vocal  bands  are  exposed  to  view. 


exposed.  The  last  is  fixed  at  its  lower  border  with  a 
sharp  hook,  and  a  sharp-pointed  knife  is  introduced 
through  the  cricothyroid  ligament  into  the  lumen  of  the 
larynx.  Through  this  opening  the  thyroid  cartilage  is 
divided  with  scissors,  with  a  blunt-pointed  knife,  or,  if 
necessary,  with  bone-scissors,  accurately  in  the  middle 
line  upward  to  the  thyrohyoid  ligament.  The  lateral 
halves  of  the  divided  thyroid  cartilage  are  held  apart  by 
means  of  sharp  tenacula,  exposing  the  interior  of  the 
larynx  to  operative  attack  (Plate  13).  In  accordance 
with  the  nature  of  the  conditions  leading  to  operation,  the 
larynx  may  be  kept  open  for  subsequent  treatment.  Un- 
der other  conditions  the  halves  of  the  thyroid  cartilage 
and  the  overlying  skin  are  closed  by  knotted  suture.  For 
the  first  days  after  the  operation,  during  the  process  of 
healing,  the  entrance  of  air  into  the  lungs  js  insured 
through  a  cannula  introduced  into  the  trachea. 

Crkothyrotoiny,  opening  the  larynx  through  the  crico- 
thyroid ligament,  can  if  necessary  be  executed  in  the 
shortest  possible  time  by  reason  of  the  superficial  situation 
of  the  cricothyroid  ligament.  On  this  account  cricothyrot- 
omy  is  the  operation  preferred  to  prevent  acute  suffoca- 
tion following  occlusion  of  the  larynx  by  a  foreign  body, 
in  cases  of  laryngospasm,  etc.  A  short  cutaneous  incision 
is  made  from  the  middle  of  the  prominence  of  the  thyroid 
cartilage  downward  beyond  the  cricoid  cartilage  (Fig. 
177,  d).  If  delay  be  dangerous,  the  lower  extremity  of 
the  cricoid  cartilage  may,  after  division  of  the  skin,  be 
grasped  and  held  securely  with  a  sharp  tenaculum  passed 
through  the  ligament.  *  If  the  operator  has  convinced 
himself  by  touch  with  the  finger  as  to  the  position  of  the 


Tab.   13. 


LiiJi.  .-ui.^i 


OPERATfOSS  OX  THE  AIR-PASSAGES.  271 

lioTimont,  this  is  cautiouslv  incised  in  the  middle  line  with 
a  sharj)-p<)inted  knife  until  a  sensiition  is  eonveyeil  throujrh 
the  in.-lninient  of  haviuir  entered  the  lumen  of  the  larvnx. 
At  once  the  openin*;  in  the  ligament  is  made  to  ga}>e  l)y 
means  of  a  ln>ok  inserted  on  either  side,  and  if  uecessarv 
the  ligament  is,  further,  notched.  The  cannula  is  intro- 
duced into  the  opening  thus  made  and  the  h(^)oks  are  re- 
moved from  the  wound.  By  this  mcxle  of  procedure  there 
is  no  loss  of  blood  and  the  cannula  lies  so  snugly  within 
the  wound  as  to  constitute  a  sort  of  tampon.  If  there  be 
surticient  time  for  the  performance  of  the  openition  the 
cutaneous  incision  is  made  longer  and  the  cricothyroid 
ligament  is  laid  bare  by  careful  dissection.  After  the 
subcutaneous  connective  tissue  has  been  passed  the  cervi- 
cal fascia  is  divided  and  the  cricothyroid  lig-ament  is  ex- 
posed. The  lower  border  of  the  cricoid  cartilage  is  raised 
up  by  means  of  a  simple  sharp  tenaculum,  which  is  intro- 
duced inti^  the  middle  line,  when  the  ligament  is  divided 
vertically  and  a  cannula  is  introduced.  If  necessary,  the 
longitudinal  incision  in  the  ligament  is  notched  on  the  right 
and  the  left.  Through  the  crucial  incision  thus  formed 
the  cannula  is  readily  introduced.  The  latter  is  held  in 
place  in  the  wound  by  means  of  linen  tapes  attacheil  to 
the  shield  of  the  cannula,  and  tied  at  the  nape  of  the 
neck. 

Extirpation  of  the  Larjmx. — If  removal  of  the  larynx 
is  to  be  conjoine<:l  with  larvngotissure,  to  the  longitudinal  in- 
cision a  transverse  incision  is  added  at  the  level  of  the  hyoid 
bone,  when,  after  division  of  the  muscular  attachments  to 
the  lower  surface  of  the  hyoid  bone,  the  thyrohyoid  mem- 
l)rane  is  divided  in  corresi>i^ndence  with  the  superficial 
transverse  incision.  The  soft  parts  on  the  outer  side  are 
to  be  separated  close  to  the  laryngeal  cartilages.  Ujxm 
the  j)05terior  aspei't  the  cricoid  cartilage  is  freed  from  its 
loose  attachment  to  the  anterior  wall  of  the  esophagus. 
If  the  upper  and  lower  boundaries  of  the  larynx  also 
have  been  incised  upon  the  mucous  surface,  the  larynx  is 
completely  freeil  after  transverse  division  of  the  trachea 


278  OPERATIVE  SURGERY. 

below  the  larynx.  Tlie  deficiency  left  in  the  anterior 
portion  of  the  pharynx  and  esophagus  is  reduced  to  a 
niininiuni  l)y  suture.  The  cannula  is  left  in  the  trachea. 
The  wound  remains  open  and  is  tamponed. 

Tracheotomy. — Tracheotomy  consists  in  properly  open- 
ing the  trachea  through  incision.  The  procedure  is  in  all 
cases  attended  with  the  introduction  of  a  cannula  through 
the  opening  into  the  trachea. 

Indications : 

(1)  Injuries  of  the  larynx  (punctured,  incised,  and  gun- 
shot-wounds, fractures  of  the  laryngeal  cartilages  with  dis- 
location of  the  fragments). 

(2)  The  presence  of  foreign  bodies  in  the  trachea  which 
cannot  be  removed  by  endolaryngeal  procedures. 

(3)  Stenosis  of  the  larynx  and  the  trachea  : 

(a)  Compression-stenosis  (goitrous  tumors,  aneurysms) ; 

(6)  Occlusion-stenosis  (obstruction  of  the  lumen  of  the 
larynx  or  the  trachea,  swelling  of  the  laryngeal  mucous 
membrane — diffuse  submucous  laryngitis ;  tuberculous, 
syphilitic,  and  typhoid  disease  of  the  larynx).  Narrow- 
ing of  the  lumen  of  the  larynx,  or  of  the  trachea,  through 
exudates  (diphtheric  croup),  through  neoplasms  (carci- 
noma, papilloma,  granulation-tumors) ; 

(c)  Cicatricial  narrowing  of  the  larynx  (after  healing 
of  ulcerative  processes ;  after  operative  procedures  upon 
the  larynx. 

(4)  As  a  preliminary  operation,  or  in  conjunction  with 
other  operations  upon  the  larynx  and  the  pharynx,  trache- 
otomy is  performed  : 

{a)  To  prevent  the  entrance  of  blood  into  the  bronchi 
(tampon-cannula) ; 

(6)  Following  operations  upon  the  larynx,  without 
leaving  an  opening  or  with  closure  by  tampon,  in  order 
to  supply  the  patient  with  air. 

(5)  Asphyxia  or  intoxieation,  to  render  possible  and 
to  institute  artificial  respiration. 

The  trachea  is  the  direct  contmuation  of  the  larynx, 
passing  in  the  middle  line  of  the  neck  toward  the  upper 


OPERATIONS  ON  THE  AIR-PASSAGES.  279 

npcM'tnrc  of  tlic  tlioi-.tx.  Tlic  ii])|)('r  ])<)rti(>n  of'tlic  traclica 
lies  iiniiicdiatcly  Ix-ncath  tlie  .supcrlicial  .structures  of"  tlic 
neck.  The  su})rastL'riial  portion  is  separated  from  the 
skin,  in  addition  to  the  two  layers  of  cervical  fascia,  by  a 
considerable  layer  of  cellular  tissue  containing  numerous 
veins.  The  thyroid  gland  overlies  the  trachea  between 
the  third  and  sixth  cartilaginous  rings  ^vith  its  lateral 
lobes  connected  by  the  isthnuis.  Often  a  pyramidal  lobe 
of  the  thyroid  gland  covers  also  the  upper  portion  of  the 
trachea.  The  anterior  surface  of  the  trachea  and  of  the 
thyroid  gland  is  covered  by  the  muscles  passing  from  the 
sternum  to  the  hyoid  bone  and  the  thyroid  cartilage 
(sternohyoid,  sternothyroid).  In  the  middle  line,  between 
the  muscles,  a  strip  of  trachea  is  covered  only  by  the 
cervical  fascia.  It  is  through  this  "  white  line  of  the 
neck  "  that  the  trachea  is  attacked.  The  isthmus  of  the 
thyroid  gland  divides  the  trachea  into  two  parts,  a  supra- 
thyroid  and  an  infrathyroid.  The  opening  through  the 
former  constitutes  superior  tracheotomy ;  that  through 
the  latter,  inferior  tracheotomy. 

Superior  Tracheotomy. — The  patient  lies  in  the  dorsal 
decubitus,  with  the  neck  over-extended,  and  a  cylindric 
pillow  is  placed  beneath  the  shoulders.  The  operator 
stands  upon  the  right  side  of  the  patient  and  his  assistant 
upon  the  opposite  side.  The  cutaneous  incision  is  made 
accurately  in  the  median  line  of  the  neck  from  the  middle 
of  the  thyroid  cartilage  to  below  the  thyroid  gland. 
After  the  skin  and  the  subcutaneous  connective  tissue 
have  been  passed  the  tense  fascia  of  the  neck  is  divided 
upon  a  grooved  director.  The  inner  borders  of  the  sterno- 
hyoid nniscles  come  into  view,  and  are  retracted  sym- 
metrically with  blunt  hooks.  The  situation  of  the  trachea 
is  determined  by  palpation  with  the  finger,  and  its  first 
cartilaginous  ring  is  exposed  by  detaching  the  cellular 
tissues  from  the  trachea  by  means  of  two  pairs  of  ana- 
tomic forceps.  The  field  of  operation  is  extended  through- 
out a  sufficient  extent  by  incising  the  layer  of  fascia 
stretched  between  the  upper  border  of  the  thyroid  gland 


280  OPERATIVE  SURGERY. 

Plate  14. — Inferior  Tracheotomy. 

The  wound  is  bounded  laterally  by  the  sternohyoid  muscles.  The 
trachea  is  exposed  and  opened  upon  its  anterior  aspect  for  the  introduc- 
tion of  the  cannula.  Venous  branches  (middle  thyroid  veiusj  are  seen 
passing  downward  from  the  thyroid  gland.  Lying  close  to  the  right  of 
the  trachea  in  the  depth  of  the  wound  is  the  innominate  artery. 

and  the  trachea,  and  dislocating  the  gland  downward  by 
means  of  blunt  hooks.  Before  proceeding  with  the  open- 
ing of  the  trachea  the  upper  rings  must  be  thoroughly 
exposed  by  dissection.  Then  the  trachea  is  grasped  just 
below  the  cricoid  cartilaginous  ring  accurately  in  iho 
middle  line  with  a  simple  sharp  tenaculum,  raised  some- 
what and  held  fixed  in  this  position.  The  trachea  is  then 
incised  accurately  in  the  middle  line  from  below  upward 
for  a  distance  of  al^out  1  cm.  with  a  sharp-pointed  knife. 
The  opening  thus  made  is  distended  by  means  of  shai'p 
tenacula  and  possibly  nicked  on  either  side.  AVhile  the 
three  tenacula  are  held,  undisturl)ed,  in  place,  the  ope- 
rator introduces  the  cannula  into  the  trachea.  The  cuta- 
neous wound  is  reduced  in  size  by  knotted  sutures  and 
the  cannula  is  firmly  fixed  in  place  by  means  of  tapes. 
Inferior  Tracheotomy. — The  patient  is  placed  in  the 
same  position  as  in  the  performance  of  superior  trache- 
otomy and  a  cutaneous  incision  is  made  from  the  lower 
border  of  the  thyroid  gland  to  below  the  suprasternal 
fossa  (Fig.  177,  c).  After  the  skin  and  the  subcutaneous 
connective  tissue  have  been  penetrated  the  superficial 
layer  of  the  cervical  fascia  is  exposed  and  divided  upon  a 
grooved  director  in  the  direction  of  the  cutaneous  incision. 
A  considerable  layer  of  loose  connective  tissue  is  passed 
through  by  means  of  two  pairs  of  anatomic  forceps,  while 
the  inner  border  of  the  sternoliyoid  muscle  on  either  side 
is  retracted.  In  the  dense  layer  of  connective  tissue  the 
middle  thyroid  veins  pass  vertically  downward  to  the  left 
innominate  vein,  and  nuist  be  avoided  or  possibly  ligated 
in  two  ])laces  and  divided  between.  During  the  progress 
of  the  blunt  dissection  the  situation  of  the  trachea,  toward 


Tab.    14. 


Lith.  Arist  E  Heichhold,  Miiiuhen 


OPERATIONS  ON  THE  AIR-PASSAGES. 


281 


the  convex  aspect  of  which  tlie  operation  proceeds,  should 
be  constantly  kept  in  mind  by  palpation  with  the  index- 
finger.  Before  the  traehea  is  reaelicd  the  deep  layer  of 
the  cervical  fascia  is  divided  upon  a  grooved  director. 
Only  after  this  has  been  done  is  it  possible  to  isolate  the 
treaehea  adecjuately.  Before  the  lumen  of  the  tube  is 
opened  the  trachea  is  grasped  with  a  simple  sharp  tenacu- 


X  .• 


,J 


Fig.  177. — Cutaneous  incisions  on  the  neck  :   a,  infrahyoid  pharyngot- 
omy  ;  b,  cricothyrotomy  ;  c,  inferior  tracheotomy. 

lum  and  raised  and  fixed  at  the  level  of  the  skin.  AMiile 
the  trachea  is  incised  from  below  upward  the  index-finger 
of  the  left  hand  is  placed  in  the  lower  angle  of  the  woimd 
behind  the  suprasternal  notch,  so  that  the  left  innominate 
vein,  which  passes  transversely  across  the  trachea  behind 
the  manubrium  of  the  sternum,  as  well  as  the  innominate 
artery,  whieh  is  in  close   relation  with  the  traehea,  is  suf- 


282  OPERATIVE  SURGERY. 

liciently  protected.  The  tracheal  wound  is  held  Avidely 
open  by  means  of  sharp  tenacula,  possibly  incised  to  right, 
and  left,  when  the  introduction  of  the  cannula  is  under- 
taken (Plate  14). 

After  the  cannula  has  been  introduced  into  the  trachea 
the  tenacula  are  removed.  The  cannula  is  fixed  by  means 
of  tapes  and  the  cutaneous  wound  is  reduced  by  suture. 
If  the  tracheotomy  can  be  performed  at  leisure  and  under 
favorable  conditions,  the  typical  mode  of  procedure  is 
unattended  with  difficulty.  The  reverse  is  the  case,  how- 
ever, if  the  operation  must  be  undertaken  in  the  presence 
of  threatened  danger  to  life  or  of  severe  dyspnea.  Under 
these  circumstances  all  of  the  presence  of  mind  of  the 
operator  will  bo  required  to  maintain  the  mastery  of  the 
situation,  which  is  often  a  critical  one.  The  smallest 
veins  of  the  neck  are  dilated  and  distended  with  blood. 
In  the  presence  of  conditions  like  these  the  cutaneous 
incision  is  enlarged,  as  by  this  means  the  isolation  and 
lio:ation  of  the  veins  are  considerablv  facilitated.  The 
thin  walls  of  the  distended  veins  are  not  readily  recog- 
nizable. Veins  that  interfere  with  deep  dissection  are 
ligated  in  two  places  and  divided  between.  At  successive 
stages  of  the  dissection  the  position  of  the  trachea  is  con- 
stantly kept  in  mind.  Neglect  of  this  ])recaution  may 
lead  to  overlooking  the  trachea.  Before  the  trachea,  pre- 
viously exposed  sufficiently,  is  opened,  all  bleeding  vessels, 
are  closed  by  ligature.  A  tenaculum  is  introduced  into 
the  trachea  for  the  purpose  of  placing  the  organ  at  rest 
at  the  level  of  the  Avound,  as  it  would  otherwise  rise  and 
fall  with  the  respiratory  movements,  especially  in  the 
presence  of  dyspnea.  The  opening  into  the  trachea  should 
be  made  exactly  in  the  middle  line,  care  being  taken  that 
the  incision  enters  the  lumen  of  the  tube  and  does  not  ]^ass 
beyond.  If  the  opening  is  incomplete,  it  may  happen 
that  the  tracheal  cannula  makes  a  false  passage  for  itself 
beneath  the  mucous  membrane.  A  careless  incision  may, 
further,  injure  the  posterior  wall  of  the  trachea  or  even 
the  esophagus.     After  the  trachea  has  been  opened  the 


OPERATIONS  ON  THE  AIR-PASSAGES. 


283 


incision  is  dilated  hy  means  of  tenacula,  while  at  the  same 
time  as  the  cannula  is  introduced  the  trachea  is  held 
steadily.  The  latter  precaution  is  important,  as  through 
its  neglect  the  o{X'ning  may  be  lost  to  view  in  consequence 
of  the  movements  of  the  trachea.  A])art  from  the  fact 
that  such  an  event  may  render  impossible  the  proper  in- 
troduction of  the  cannula,  subcutaneous  emphysema  may 
result  and  extend  from*  the  wound  to  the  cellular  tissue  of 
the  neck. 

The  cannula  (Fig.  178)  in  accordance  with  its  curvature 
is  introduced  in  an  arched  manner.     The  whistling  sound 


Fig.  178. — Tracheal  cannula. 


Fig.  179. — Trendelenburg's  tampon- 
cannula. 


with  which  the  air,  after  a  short  period  of  apnea,  escapes 
from  the  tube  is  the  indication  that  the  cannula  is  properly 
placed.  In  tixing  the  cannula  by  means  of  the  tapes  the 
tube  must  be  held  firmly  in  the  wound. 

Tracheotomy  for  the  puqx)se  of  tamponade  of  the 
trachea,  with  simultaneous  insurance  of  access  of  air,  is 
sometimes  ])ractised  as  a  preliminary  procedure  in  opera- 
tions upon  the  mouth,  the  larynx,  and  the  pharynx.  The 
tampon-cannula  is  intended  to  prevent  the  entrance  of 
blood  in  the  course  of  operations  and  the  aspiration  of 


284  OPERATIVE  SURGERY. 

secretion  from  wounds  in  the  further  progress  of  the  case. 
The  so-called  tampon-cannula  employed  for  this  purpose 
is  surrounded  with  compressed  sponge  (Hahn),  which 
swells  in  the  trachea  and  completely  occupies  its  lumen ; 
or,  the  tube  is  surrounded  l^y  a  small  rubber  bag  (Tren- 
delenburg) which  can  be  filled  with  air  by  means  of 
bellows  (Fig.  179).  The  l)ag  is  distended  with  air  after 
the  cannula  has  l^een  introduced,  and  adapts  itself  accu- 
rately to  the  interior  of  the  trachea,  occluding  its  lumen 
as  a  stopper  does  the  neck  of  a  flask. 

Intubation. — Intubation  is  a  bloodless  procedure  in- 
tended to  render  the  larynx  patulous  in  the  presence 
of  respiratory  obstruction  by  the  introduction  of  a  rigid 
tube.  The  operation  was  recommended  a  number  of 
years  ago  as  a  substitute  for  tracheotomy  in  cases  of 
laryngeal  stenosis  from  croup,  and  it  has  in  the  course 
of  time  secured  more  and  more  supporters. 

The  most  important  indication  for  intubation  consists  in 
laryngeal  stenosis  such  as  is  observed  in  conjunction  with 
laryngeal  croup.  Further  indications  are  afforded  by  the 
various  forms  of  chronic  stenosis  of  the  larynx  observed 
in  adults.  Under  these  conditions  intubation  is  a  substi- 
tute for  tubage.  Intubation  has  been  recommended  also 
as  a  palliative  measure  in  cases  of  whooping-cough  and  of 
laryngeal  spasm.     The  procedure  is  contraindicated  : 

(a)  In  the  presence  of  complete  occlusion  of  the  naso- 
pharyngeal space ; 

(6)  In  the  presence  of  intense  edema  of  the  glottis ; 

(c)  In  cases  of  diphtheria  complicated  by  retrophar^m- 
geal  abscess. 

The  original  outfit  of  O'Dwyer  is  still  the  best,  in  spite 
of  numerous  modifications.     This  consists  of: 

(1)  A  mouth-gag  (Fig.  180). 

(2)  A  series  of  metallic  tubes  of  varying  size  (Figs. 
181  and  182).  Each  tube  presents  at  its  upper  extremity 
a  shoulder  resembling  the  rim  of  a  hat,  by  means  of  which 
it  rests  upon  the  vocal  bands.  Upon  the  left  side  of  this 
shoulder  is  a  small  opening  for  the  attachment  of  a  thread. 


OPKRATIOSS   O.V    Tin:   mi:- PASSAGES. 


285 


Each  tube  i.s  t'lirtlu'r  provided  with  a  conductor  intended 
to  facilitate  the  iriiidance  of  the  rigid  tube. 

(3)  An  intul)ator  (Fig.  183),  to  which  the  conductor 
spoken  of  is  attached  by  means  of  a  screw.  Tube  and 
conductor  should  tit  accurately.  By  means  of  a  lever  the 
tube  can  be  detached  from  the  conductor  at  the  proper 
moment. 

(4)  An  extubator  (Fig.  184).  The  extremity  of  this 
instrument,  which  is  constructed  similarly  to  the  intuba- 
tor,  can  be  introduced  into  the  lumen  of  the  tube,  and  be 
impacted  there,  and  thus  serve  for  the  removal  of  the 
tube. 

ODWYEKS   OUTFIT    FOR    INTUBATION. 


Fig.  180.— Mouth-gag.      Fig.  181  and  Fig.  132.— Tubes  with  conductors. 


The  operation  is  j)erformed  as  follows  : 

A  nurse  takes  the  child  to  be  intubated  \\\)on  her  lap, 
grasps  its  lower  extremities  between  her  knees,  and  with 
her  right  hand  holds  its  head, and  with  her  left,  its  hands. 
An  assistant  holds  the  mouth  oj)en  by  means  of  the  gag, 
while  the  operator  grasps  the  epiglottis  with  the  index- 
linger  of  his  left  hand  and  draws  it  forward  so  that  the 
entrance  to  the  larynx  is  clear.  The  intulmtor,  adapted 
to  the  corresponding  tube,  is  no'w  introduced  alongside  the 
finger.  If  after  a  slight  movement  upward  it  is  certain 
that  the  tube  has  entered  the  larvnx.  the  former  is  then 


286 


OPERATIVE  SURGERY. 


Plate  15. — Infrahyoid  Pharyngotomy. 

Preliminary  inferior  tracheotomy  has  been  performed  and  a  cannula 
introduced.  In  the  pharyngotomy-wound  can  be  seen  the  stumps  of  the 
divided  hyoid  muscles,  as  well  as  the  hyoid  bone  iH ). 

The  epiglottis  {E )  is  drawn  out  of  the  wound  and  the  aryepiglottic 
folds  {Ae)  are  made  tense.  The  lloor  of  the  wound  is  constituted  by  the 
posterior  wall  of  the  pharynx. 


pushed  gently  onward,  detached  from  the  intubator,  either 
M'itli  the  finger  of  the  left  hand  or  by  means  of  slight 
pressure  forward  upon  a  sliding  arrangement  connected 
Avith  the  handle  of  the  instrument,  and  with  the  index- 
finger  of  the  left  hand  forced  deeply  into  the  larynx.  If 
the  child  breathes  freely,  the  thread  attached  to  the  tube 
may  be  permitted  to  remain,  being  brought  out  of  the 


Fig.  184.— Extubator. 


mouth  and  attached  to  the  cheek  by  means  of  adhesive 
plaster,  or  the  index-finger  is  again  introduced  into  the 
mouth,  the  tube  held  in  place,  and  the  divided  thread 
slowlv  removed. 

Extubation  is  effected  in  much  the  same  manner. 
Under  the  guidance  of  the  index-finger  of  the  left  hand 
the  extubator  is  introduced  into  the  mouth  and  its  closed 


Tab.   15. 


J.ith        '"■•'     A'   /,'<v//.A /,/,///       \/,,Ti,-/,n, 


orKRATloys   ON  THE  AIll-PASSAaKS.  287 

blades  arc  passed  into  tlie  lumen  of  the  tube.  By  press- 
ure Uj)()U  the  u|)})er  portion  of  the  instrument  its  two 
blades  are  separated  and  the  tube  ean  thus  be  eare fully 
removed. 

In  most  cases  of  intubation  the  use  of  the  mouth-ira^ 
ean  be  dis])ensed  with.  Under  such  circumstances  the 
index-tinii'er  of  the  left  hand  must  be  protected  by  a 
metallic  band. 

Pharyngotomy. — The  pharynx  can  be  opened  in  its 
laryngeal  portion  by  transverse  division  of  the  thyrohyoid 
ligament.  By  this  means  the  pharyngolaryngeal  space  is 
exposed  to  view.  This  mode  of  opening  the  pharynx  and 
the  larynx  (]Malgaigne's  infrahyoid  larvngotoniy)  is  suit- 
able for  the  })erformance  of  surgical  operations  upon  the 
epiglottis,  in  the  larynx,  and  upon  the  pharynx. 

Infi-ahyoid  pharyngotomy  is  performed  : 

For  the  removal  of  foreign  bodies  from  the  larynx  and 
the  pharynx ; 

For  the  extirpation  of  tumors  of  the  epiglottis,  the 
larynx,  and  the  pharynx  ; 

In  the  treatment  of  cicatricial  strictures  of  the  esopha- 

Steps  of  the  Operation. — The  patient  is  placed  in  the 
dorsal  decubitus  Avith  the  cervical  portion  of  the  spinal 
column  overextended,  and  preliminary  tracheotomy  is 
performed.  By  means  of  palpation  Avith  the  finger  the 
position  of  the  hyoid  bone  and  of  the  thyroid  cartilage  is 
determined.  The  cutaneous  incision  is  made  transversely 
over  the  thyrohyoid  ligament  parallel  with  and  close  to  the 
body  of  the  hyoid  bone  (Fig.  177,  a).  After  the  cervical 
fascia  has  been  opened  and  the  sternohyoid  and  thyro- 
hyoid muscles  have  been  divided  transversely  the  mem- 
brane is  exposed  to  view.  It  is  detached  from  the  pos- 
terior surface  of  the  hyoid  bone  and  the  pharynx  is  opened 
in  the  middle  line  at  the  up])er  border  of  this  l)one.  By 
this  method  only  is  the  epiglottis  protected,  falling  down- 
ward after  division  of  the  hyo-epiglottic  ligament,  when 
also  the  lateral  portions  of  the  thyrohyoid  ligament  may  be 


288  OPERATIVE  SURGERY. 

divided  with  a  single  stroke  of  the  scissors.  The  epiglot- 
tis, the  aryepiglottic  folds,  the  vocal  bands,  the  interior  of 
the  larynx,  as  well  as  the  laryngeal  portion  of  the  pharynx, 
are  exposed  for  possible  therapeutic  intervention  (Plate 
15). 

When  tumors  are  seated  in  the  deeper  portions  of  the 
pharynx  Langenbeck  recommends  an  incision  from  the 
middle  of  the  ramus  of  the  jaw  over  the  greater  cornu  of 
the  hyoid  bone  to  the  cricoid  cartilage.  The  lingual  and 
superior  thyroid  arteries,  as  well  as  the  facial  vein,  are 
exposed  and  divided  between  two  ligatures.  The  digas- 
tric and  stylohyoid  muscles  are  detached  from  the  hyoid 
bone,  when  the  pharynx  is  opened  in  the  direction  of  the 
cutaneous  incision. 

External  Esophagotomy. — Opening  of  the  esophagus  in 
the  neck  is  indicated  : 

(1)  In  the  presence  of  foreign  bodies  in  the  esophagus ; 

(2)  In  the  presence  of  impermeable  high  stenoses  of  the 
esophagus,  from  carcinoma  or  cicatricial  stricture,  for  the 
formation  of  a  nutritive  fistula  beyond  the  narrowed  situ- 
ation ; 

(3)  In  the  presence  of  cicafricial  strictures  more  deeply 
seated  : 

(a)  For  the  performance  of  dilatation  through  a  fistula 
established  ; 

(6)  For  the  performance  of  internal  esophagotomy  from 
the  wound  (Gussenbauer's  combined  esophagotomy). 

The  esophagus  is  opened  just  below  the  pharynx,  be- 
yond the  cricoid  cartilage,  where  it  lies  behind  the  trachea 
and  projects  upon  its  left  side.  The  inferior  laryngeal 
nerve,  which  passes  from  below  upward  between  the 
trachea  and  the  esophagus,  must  be  protected.  The  pa- 
tient is  placed  in  the  dorsal  decubitus,  with  the  cervical 
spine  overextended  and  the  head  directed  toward  the 
right.  The  cutaneous  incision  is  made  along  the  anterior 
border  of  the  sternomastoid  muscle  as  in  the  operation  for 
ligation  of  the  common  carotid  artery.  The  sheath  of 
this  muscle  is  opened  and  the  muscle  itself  retracted  out- 


OPEEATIOyS  oy  TllK  AIIl-PASSAGEK 


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LIGATION  OF   VESSELS  IN  CERVICAL  REGION.      291 

ward.  The  deep  layer  of  the  cervical  fascia  is  divided 
ujxm  a  L;;r<K)V('d  director  and  the  whole  mass  of  vessels 
and  nerves  is  likewise  displaced  ontward  with  blunt  hooks. 
\^  the  thyroid  <rland  is  at  the  same  time  dislocated  inward, 
the  trachea  comes  into  view  and,  behind  it,  projecting 
somewhat  l)eyon(l  its  left  border,  the  esophaii-us,  which  is 
to  be  reco":nized  bv  its  diilerent  color  and  the  lon^ritudinal 
arrangement  of  its  fibers.  The  gullet  is  grasped  with 
fixation-threads,  drawn  to  the  level  of  the  wound  and 
opened  in  correspondence  with  the  cutaneous  incision 
(Fig.  185).  If  the  operation  has  been  so  performed  that 
the  wound  in  the  esophagus  can  be  closed  for  primary 
union — f<>r  instance,  after  extraction  of  foreiirn  bodies — 
the  wall  of  the  esophagus  is  approximated  with  knotted 
sutures  in  two  tiers.  The  first  row  of  sutures  approxi- 
mates the  mucous  membrane  and  the  second  the  muscular 
layer.  If  the  operation  has  been  performed  for  the  pur- 
pose of  establishing  an  esophageal  fistula — for  instance, 
for  dilatation  of  a  stricture  of  the  esophagus — the  margins 
of  the  mucous  membrane  are  united  to  the  skin  by  means 
of  knotted  sutures. 

lyigation  of  Vessels  in  the  Cervical  Region. — 
Innominate  Artery. — The  innominate  artery,  the  common 
trunk  of  the  carotid  and  the  right  subclavian  artery,  arises 
from  the  arch  of  the  aorta.  Lying  against  the  trachea, 
the  large  vessel  passes  to  the  right  and  upward,  dividing 
into  the  two  vessels  named  at  the  level  of  the  sterno- 
clavicular articulation.  Covered  bv  the  manubrium  of 
the  sternum,  the  innominate  artery  is  accessible  from  the 
suprasternal  fossa  behind  the  free  border  of  the  sterno- 
hyoid or  of  the  sternothyroid  muscle.  The  trunk  of  the 
vessel  is  crossed  by  the  left  innominate  vein  as  it  passes 
transversely.  The  recurrent  laryngeal  nerve  winds  around 
the  innominate  artery.  In  ligating  the  vessel  the  patient 
occupies  the  dorsal  decubitus,  with  the  neck  extended. 
According  to  Graefe,  the  cutaneous  incision  is  made  along 
the  anterior  border  of  the  sternomastoid  muscle  in  such  a 
way  that  its  lower  extremity  extends  beyond  the  sternal 


292  OPERATIVE  SURGERY. 

attachment  of  the  muscle.  The  sheath  of  the  muscle  is 
opened  and  the  median  fascia  of  the  neck  divided,  when 
the  inner  border  of  the  sternohyoid  becomes  visible  and 
below  tliis  that  of  the  sternothyroid.  These  muscles  are 
retracted  witli  blunt  hooks.  Along  the  right  side  of  the 
trachea  progress  is  made  downward,  the  common  carotid 
artery  being  first  reached  and  further  on  the  innominate, 
lying  by  the  side  of  the  trachea.  The  artery  can  be  iso- 
latecl  from  the  surrounding  loose  cellular  tissues  by  blunt 
dissection  and  it  is  then  ligated. 

The  same  plan  of  procedure  is  followed  in  looking  for 
the  vessel  through  an  incision  made  vertically  in  the  mid- 
dle line  of  the  neck  over  the  suprasternal  notch^  instead 
of  the  incision  of  Graefe. 

Carotid  Artery. — The  carotid  artery  on  the  right  is  a 
branch  of  the  innominate,  while  upon  the  left  it  arises 
directly  from  the  arch  of  the  aorta.  The  common  carotid 
artery  on  either  side  passes  along  the  side  of  the  trachea 
and  the  larynx  almost  vertically  upward  upon  the  neck  to 
the  level  of  the  thyroid  cartilage,  where  it  divides  into  its 
primary  branches,  the  internal  and  the  external  carotid.  In 
its  course  the  carotid  artery  holds  such  relations  with  the 
jugular  vein,  the  vagus  nerve,  and  the  descending  branch 
of  the  hypoglossal  nerve  in  the  loose  cellular  tissue  that 
the  vein  lies  to  the  outer  side  of  the  artery.  The  vessels 
are  covered  by  fibrous  fascia  that  also  constitutes  the  poste- 
rior w^all  of  the  sheath  of  the  sternomastoid  muscle.  To 
render  the  artery  accessible  it  will  thus  be  necessary  to 
expose  and  retract  the  fibers  of  the  sternomastoid  muscle 
and  to  divide  carefully  the  posterior  wall  of  its  sheath. 

Ligation  of  the  Common  Carotid  Artery. — The  patient 
occupies  the  dorsal  decubitus,  Avith  the  neck  stretched  and 
the  head  rotated  toward  the  healthy  side.  By  palpation 
the  situation  of  the  larynx  and  the  course  of  the  sterno- 
mastoid muscle  are  determined.  The  artery  is  best  ex- 
posed at  the  level  of  the  cricoid  cartilage  just  above  the 
point  where  it  is  crossed  by  the  omohyoid  muscle.  The 
cutaneous  incision  is  made  along  the  anterior  border  of  the 


LIGATION  OF  VESSELS  IN  CERVICAL  REGION.     293 

sternoinastcud  from  the  thyroid  ciirtihige  for  a  distance 
downward  of  8  or  10  cm.  (Fig.  186, />;).  After  the  skin 
and  the  platysma  muscle  are  divided  the  sternomastoid 
muscle,  covered  hy  the  fascia,  comes  into  view.  The 
fascia  is  divided  in  the  direction  of  the  cutaneous  incision 
and  the  inner  border  of  the  exposed  muscle  is  carefully 
retracted  outward,  when  the  so-called  middle  fascia  of  the 


Fig.  186. — Ligation  of  the  vessel-  t<i  the  i-_  .: ;  -;raneous  incision:  a, 
lingual  artery:  6,  common  carotid  artery;  c,  subclavian  artery  above  the 
clavicle  ;  d,  subclavian  artery  below  the  clavicle. 


neck  and  the  omohyoid  muscle  come  into  view.  Above 
this  muscle  the  fascia  is  divided  carefully  upon  the  grooved 
director  and  the  artery  isolated  by  blunt  dissection  and 
raised  out  of  its  bed.  To  the  outer  side  of  the  arter}'  lies 
the  internal  jugular  vein,  and  between  the  two  vessels 
the  vagus  nerve. 

Ligation  of  the  External  Carotid  Artery. — The  patient 


294  OPERATIVE  SURGERY. 

Plate  I 6. 

(1)  Exposure  of  the  carotid  artery  in  the  neck.  The  sternomastoid 
muscle  (K)  is  retracted  outward;  the  deep  layer  of  the  cervical  fascia 
(F.c.)  is  divided,  and  the  commou  carotid  artery  (C),  the  jugular  vein  {J), 
the  vagus  nerve,  and  the  descending  branch  of  the  hypoglossal  nerve  are 
thus  brought  into  view.  The  bifurcation  of  the  common  carotid  into  the 
internal  and  external  carotid  is  also  discernible.  The  origin  of  the  thy- 
roid from  the  external  carotid,  which  in  the  illustration  is  situated  ab- 
normally far  outward,  has  been  freed  by  dissection. 

(2)  Exposure  of  the  subclavian  artery  below  the  clavicle.  The  pec- 
toralis  major  muscle  (P)  is  divided  in  the  direction  of  the  cutaneous 
incision  to  the  deltoid  muscle  (D).  Below  the  former  the  subclavian 
artery  {A)  is  visible  between  the  vein  (T)  and  the  branchial  plexus  of 
nerves  (P). 

is  placed  in  the  same  position  as  in  ligation  of  the  com- 
mon carotid  artery,  and  the  incision  through  the  skin  is 
made  along  the  anterior  border  of  the  sternomastoid  mus- 
cle, with  its  upper  extremity  at  the  level  of  the  hyoid 
bone.  After  the  skin,  the  platysma  muscle,  and  the  super- 
ficial fascia  have  been  divided  the  common  facial  vein 
comes  into  view  and  is  retracted  toward  the  middle  line 
by  means  of  blunt  hooks.  The  trunk  and  the  branches 
of  the  external  carotid  artery  are  exposed  by  blunt  dis- 
section in  front  of  the  greater  cornu  of  the  hyoid  bone 
between  the  omohyoid  muscle  and  the  posterior  belly  of 
the  digastric  muscle. 

An  incision  like  that  described  suffices  also  for  the 
exposure  of  the  large  branches  of  the  external  carotid 
artery,  the  external  maxillary  (facial),  the  lingual,  and  the 
superior  thyroid,  at  their  points  of  origin,  for  purposes  of 
ligation.  Of  the  branches  of  the  external  carotid,  the 
superior  thyroid  and  the  lingual  artery  are  of  surgical 
importance. 

The  siqjerior  thyroid  artery  arises  from  the  trunk  of  the 
external  carotid,  just  above  the  bifurcation,  at  the  level  of 
the  hyoid  bone,  and  it  passes  in  an  arched  direction  down- 
ward to  the  thyroid  gland.  To  ligate  the  vessel  a  cuta- 
neous incision  is  made  along  the  anterior  border  of  the 


Tab.   16 


i: 


rist  t:  ReicMwld.  Miina. 


LIGATION  OF   VESSKLS  IX  CERVICAL  REGIOS.     295 

st«Tnnrnast<>I<l  muscle  t'nmi  tlie  hyoid  Ixmc  to  tiic  ihvruid 
cartilai^c.  Alter  «livi>iun  ot  the  <kiii,  the  phitysnia  nui^ele, 
and  tlie  wrvieal  fascia  the  vessel,  passing  downward  in  an 
arched  direction,  is  found  at  the  greater  comii  of  the  hyoid 
bone. 

The  lingiml  artery  arises  from  the  external  carotid  at 
about  the  level  of  the  hyoid  Ixnie,  and  it  passes  in  a 
slightly  curved  direction  forward  and  upward,  entering 
the  substance  of  the  tongue  under  cover  of  the  livotjlossus 
muscle. 

Ligation  of  the  Lingual  Artery. — An  arched  incision 
is  made  from  the  angle  of  the  jaw  to  the  hyoid  bone, 
thence  ascending  fn»m  this  {X)int  almost  to  the  chin  i^Fig. 
186,  a).  Atler  division  of  the  skin  and  the  platysma 
muscle  the  sujxTficial  layer  of  the  cervical  fascia  comes 
into  view  and  l)eneath  this  the  submaxillary  gland  is 
visible.  The  fascia  is  slit  oj)en  at  a  point  corresponding 
to  the  lower  margin  of  the  gland,  which  is  raised  from  its 
bed  by  blunt  dissection  and  retnicted  upward.  Covere^l 
by  the  deep  layer  of  the  cervical  tascia  may  be  seen  the 
-hinino:  tendon  of  the  disrastric  muscle  curvins:  in  an 
arched  manner,  and,  above,  the  hy{x>glossal  nerve,  accom- 
panied by  a  vein,  passes  horizontally.  The  free  border  of 
the  mylohyoid  muscle  forms  with  the  tendon  of  the  digas- 
tric muscle  and  the  hypoglossal  nerve  a  triangle  whose  floor 
is  constituted  bv  the  fibers  of  the  hvocflossus  muscle.  To 
ex|X)se  the  lingual  artery  the  fascia  covering  this  lingual 
trigone  is  first  divided.  Then  the  fibers  of  the  hvoglossus 
mus<de  ascending  vertically  from  the  hyoid  lx)ne  to  the 
tongue  and  forming  the  flo<^)r  of  the  triangle  referred  to 
must  be  separated  by  blunt  dissection,  when,  if  the  layer 
of  muscle  has  been  passed,  the  arteri'  becomes  \'isible  on 
the  floor  of  the  triangle,  and  can  be  ligate<l. 

Ligation  of  the  Subclavian  Aiiery. — The  sulx'lavian 
arterv,  on  the  right  a  branch  of  the  innominate  arte r}' and 
on  the  left  arising  directly  from  the  arch  of  the  aorta,  lies 
at  its  origin  at  the  a|)ex  of  the  pleural  cavity.  It  leaves 
this  cavity  through  the  upj>er  aperture  of  the  thorax,  and 


296 


OPERATIVE  SURGERY. 


Plate  17.— Exposure  of  the  Lingual  Artery. 

The  submaxillary  gland  (.S'm)  is  raised  from  its  bed  after  division  of 
the  skin  and  the  fascia  ;  the  lingual  trigone  is  thus  rendered  visible.  It 
is  bounded  by  the  tendon  of  the  digastric  muscle  (Bi,  the  outer  border 
'of  the  mylohyoid  muscle  (Mh),  and  the  hypoglossal  nerve  (H ),  which  is 
accompanied  by  a  vein.  The  floor  of  the  triangle  is  formed  by  the 
hyoglossus  muscle  (Hg),  the  fibers  of  which  are  separated  within  the  tri- 
angle, and  the  artery  (L)  is  thus  rendered  visible. 

reaches  the  anterior  surface  at  the  first  rib  in  the  interval  be- 
tween the  scalenus  anticus  and  medius  muscles  (posterior 
scalene  interval,  Fig.   187).     From  this  situation  it  de- 


FiG.  187. — Posterior  scalene 
interval  (L),  between  the  sca- 
lenus anticus  (.S'a)  and  the  sca- 
lenus medius  {Sm)  muscle. 


scends  toward  the  arm.     The  point  at  which  the  artery 
crosses  the  first  rib  is  marked  by  a  slight  elevation,  the 


Tab.   17. 


B. 


'fg- 


II. 


Mil. 


LIGATION  OF  VESSELS  IN  CERVICAL  REGION.     297 

tiihcrclc  ot"  JiislVaiu;  or  the  scalene  liil)erele.  The  cords 
of  the  brachial  ])lexus  also  reach  the  arm  through  the  in- 
ters al  between  the  two  scalene  muscles.  The  nerves  lie 
al)ove  and  to  i\\v  outer  side  of  the  artery  (IMate  18). 

The  subclavian  vein  passes  in  the  interval  between  the 
sternomastoid  and  the  scalenus  anticus  (anterior  scalene 
interval),  to  unite  ^vith  the  internal  jugular  vein.  The 
subclavian  vein  is  thus  separated  from  the  subclavian  ar- 
tery by  the  scalenus  anticus  muscle. 

The  subclavian  artery  is  exposed  for  ligation  above 
and  l)elow  the  clavicle  ;  in  the  supraclavicular  fossa  just 
at  the  point  where  it  lies  upon  the  iirst  rib  after  emerging 
from  the  scalene  interval ;  below^  the  clavicle  at  a  point 
corresponding  Avith  the  lower  margin  of  the  first  rib. 

Liyutlon  of  the  Subclavian  Avtcry  Above  the  Clavicle. — 
The  patient  lies  with  the  upper  portion  of  the  trunk  ele- 
vated and  the  head  rotated  toward  the  opposite  side.  The 
arm  lies  against  the  trunk.  Gentle  traction  on  the  arm 
brings  into  view  the  boundaries  of  the  supraclavicular 
fossa.  By  this  means  the  clavicle  can  be  seen,  forming 
the  base  of  the  triangular  space,  whose  anterior  boundary 
is  formed  by  the  outer  border  of  the  sternomastoid  mus- 
cle and  the  posterior  boundary  by  the  anterior  border  of 
the  trapezius.  The  plane  of  the  supraclavicular  fossa  is 
more  or  less  depressed. 

A  transverse  cutaneous  incision  is  made  parallel  with 
and  a  finger's  breadth  above  the  clavicle,  from  the  outer 
border  of  the  sternomastoid  muscle  to  the  anterior  border 
of  the  trapezius  (Fig.  186),  dividing  the  skin,  the  pla- 
tysma  muscle,  and  the  supraclavicular  nerves.  By  blunt 
dissection  a  passage  is  made  through  the  loose  connective 
tissue  of  the  supraclavicular  fossa  to  the  deep  layer  of 
fascia  that  covers  the  scalenus  muscles,  the  brachial 
plexus,  and  the  subclavian  artery.  After  the  fascia  has 
been  divided,  the  position  of  the  posterior  scalene  interval 
is  made  out,  and  the  situation  of  the  artery  is  determined 
by  palpation  with  the  finger  just  behind  the  attachment 
of  the  scalenus  anticus  to  the  first  rib,  to  the  outer  side 


298  OPERATIVE  SURGERY. 

Plate  1 8. — Situation  of  the  Subclavian  Artery  in  the 
Supraclavicular  Fossa. 

The  anterior  scalene  interval  is  visible  between  the  sternomastoid 
{K )  and  the  scalenus  anticus  (Sa)  ;  also  the  posterior  scalene  interval 
between  the  scalenus  anticus  and  the  scalenus  medius  {Sin).  Through 
the  latter  space  pass  the  nerves  of  the  brachial  plexus  (N),  and  to  the 
inner  side  of  the  nerves,  lying  upon  the  first  rib,  the  artery. 

of  the  scalene  tubercle.  The  artery  lies  upon  the  first 
rib  at  the  deepest  point  of  the  interval,  to  the  inner  side 
of  the  nerves  of  the  brachial  plexus,  and  can  be  isolated 
for  ligation  between  two  pairs  of  anatomic  forceps. 

Ligation  of  the  Subclavian  Artery  Below  the  Clavicle. — 
The  patient  occupies  the  same  position  as  in  the  operation 
just  described.  The  line  of  separation  of  the  clavicular 
portions  of  the  deltoid  and  pectoralis  major  muscles  is  in- 
dicated below^  the  clavicle  by  a  triangular  depression  (Moh- 
renheim's  triangle).  By  palpation  ^vith  the  finger  the 
situation  of  the  coracoid  process  of  the  scapula  is  care- 
fully determined,  and  a  cutaneous  incision  is  made  from  a 
finger's  breadth  belo^y  the  clavicle  to  above  the  apex  of 
the  coracoid  process.  The  clavicular  portion  of  the  pec- 
toralis major  muscle  is  divided  in  the  line  of  the  cuta- 
neous incision  and  after  division  of  the  loose  coracoclavic- 
ular  fascia  the  upper  border  of  the  pectoralis  minor  is 
exposed  and  is  retracted  downward  with  blunt  hooks.  In 
the  loose  connective  tissue  below  the  clavicle  there  appear 
in  the  direction  toward  the  anterior  scalene  interval  above, 
the  readily  accessible  subclavian  vein,  and  to  its  outer  side 
the  great  mass  constituted  by  the  brachial  plexus.  The 
artery  lies  betw^een  the  vein  and  tlie  nerves,  closer  to  the 
wall  of  the  thorax,  and  can  be  separated  from  the  loose 
cellular  tissue  by  blunt  dissection  (Plate  16).  Following 
another  method,  entrance  is  gained  to  Mohrenheim's  tri- 
angle, after  making  the  same  cutaneous  incision,  and  the 
artery  is  exposed  without  division  of  the  pectoralis  major. 
The  superficial  fascia  is  divided  and  after  separation  of 
the  margins  of  the  pectoralis  major  and  deltoid  muscles  the 


'WAk    1^ 


Sm. 


LIGATION  OF  VESSELS  IN  CERVICAL  REGION     299 

fossa  of  JMohivnhciiii  is  rciulcrcd  a(;('('ssil)U'.  In  the  (l('j)th 
of  this  fossil  thv  muss  of  vessels  and  nerves  is  visible  below 
the  clavicle  alter  division  of  the  coracoelavicular  fascia. 

Of  the  branches  of  the  subclavian  artcrv  the  follow  in<r 
are  i)\'  surgical  importance  :  the  inferior  thyroid  artery, 
which  is  liii'atcd  to  brin*;-  about  atro[)hy  of  tumors  of  th(» 
thyroid  gland  ;  the  vertebral  artery,  whose  ligation  has 
been  recommended  in  the  treatment  of  ej)ilepsy  ;  the  in- 
ternal mammary  artery,  whose  ligation  may  become  neces- 
sary in  ('(tnnection  with  contused  or  j)unctured  wounds  of 
the  anterior  wall  of  the  thorax. 

Ligation  of  the  Inferior  Thyroid  Artery. — The  arter}-  is 
exposed  for  ligation  at  the  point  where  it  lies  upon  the 
vertebral  column  (or  rather  the  longus  colli  muscle)  and 
])asses  behind  the  common  carotid  artery  in  a  curved  di- 
rection upward  and  inward  to  the  thyroid  gland.  Kocher 
has  recommended  an  oblique  incision  extending  upward 
and  outward  from  above  the  suprasternal  notch  along  the 
anterior  margin  of  the  sternomastoid.  The  common  ca- 
rotid artery  is  exposed  and  drawn  outward.  At  the  inner 
side  of  the  vessel  progr(\ss  is  made  between  the  artery  and 
the  thyroid  gland  drawn  toward  the  middle  line  down  to 
the  spinal  column,  where  the  artery  will  be  found  pur- 
suing its  characteristic  arched  course.  In  ligating  the 
vessel  care  must  be  taken  not  to  include  the  inferior  la- 
ryngeal nerve,  the  motor  nerve  of  the  larynx,  which  lies  in 
close  relation  with  the  vessel. 

Operation  for  Goiter. — As  a  result  of  the  symptoms  de- 
veloped after  total  extirpation  of  the  thyroid  gland  it  has 
been  learned  that  this  gland  is  an  indispensable  organ  of 
vital  importance  in  the  bodily  economy.  Total  removal 
of  the  diseased  thyroid  gland,  a  procedure  formerly  i)rac- 
tised  rather  commonly,  is  no  longer  justifiable  in  view  of 
recent  experiences.  The  conservative  methods  that  may 
be  em])loyed  in  the  surgical  treatment  of  goiter  consist  in 
intraglandular  enucleation  of  the  nodule  out  of  the  thyroid 
gland,  resection  of  the  gland,  and  unilateral  extirpation  of 
the  gland. 


300  OPERATIVE  SURGERY. 

Intraglandiilar  enucleation  (Porta,  Socin)  may  be  prac- 
tised in  the  treatment  of  cystic  goiter,  as  well  as  in  that 
of  circumscribed,  well-limited  goitrous  nodules.  The  cu- 
taneous incision  is  made  over  the  greatest  prominence  of 
the  tumor,  and  in  accordance  with  its  situation  either 
longitudinally  in  the  middle  line  of  the  neck,  or  trans- 
versely in  an  arched  direction  with  its  concavity  upward 
(Kocher).  After  division  of  the  skin  and  the  platysma 
muscle  the  several  lower  hyoid  muscles  spread  out  over 
the  thyroid  swelling  come  into  view  and  are  either  divided 
or  retracted  with  hooks,  in  accordance  with  the  direction 
of  the  cutaneous  incision.  The  capsule  of  the  goiter,  as 
Avell  as  the  healthy  parenchyma  of  the  thyroid  gland 
overlying  the  goitrous  nodule,  is  to  be  divided,  when 
the  nodule  or  the  cyst  is  removed  from  its  bed  by  blunt 
dissection  and  extirpated.  Division  of  the  nodule  and 
isolated  removal  of  its  two  halves  constitute  a  modifica- 
tion of  enucleation  recommended  by  Kocher. 

Unilateral  Strumedomy. — A  longitudinal  cutaneous 
incision  is  made  either  in  the  middle  line  of  the  neck,  or 
along  the  anterior  border  of  the  sternomastoid  muscle  ;  or 
an  angular  incision  (Kocher)  is  begun  at  the  level  of  the 
larynx  upon  the  prominence  of  the  sternomastoid  muscle, 
passing  transversely  to  the  middle  line  of  the  neck,  and 
thence  downward  to  the  suprasternal  notch.  The  trans- 
verse arched  incision  of  Kocher's  follows  the  line  of  the 
folds  of  the  neck.  After  the  superficial  layer  of  the  cer- 
vical fascia  has  been  divided  the  anterior  border  of  the 
sternomastoid  muscle  is  isolated  and  retracted  outward. 
The  fascia  further  is  divided  in  the  median  line,  when  the 
margins  of  the  lower  hyoid  muscles  are  freed  in  the  neigh- 
borhood of  the  larynx  and  divided  transversely,  so  that 
the  goiter  is  exposed  throughout  a  large  extent  of  its 
anterior  surface.  The  capsule  is  divided  and  detached 
from  the  goiter  from  within  outward,  when  the  latter,  if 
its  lateral  attachment  has  been  freed,  is  raised  out  of  its 
bed  and  displaced  from  without  inward.  After  the  upper 
and  lower  poles  of  the  tumor  also  have  been  isolated,  the 


LIGATIoy  OF   VESSELS  AV  CERVICAL  REGION.      301 

])rin('ij>al  vessels  of  tlic  thyroid  j^hirid,  tlic  siijH'rior  and 
interior  thyroid  arteries,  and  at  the  lower  pole  the  middle 
thyroid  vein  also,  are  grasped  and  divi<h'd  each  between 
two  lii^atiires.  In  liLTiiting  th<'  inferior  thyroid  artery  eare 
must  he  taken  to  avoid  the  inferi(^r  laryniical  nerve,  which 
lies  in  immediate  i)roximity  with  the  trunk  of  the  arterv. 
The  thyroid  isthmus,  whieh  is  rendered  accessible  hy  lift- 
iiisj:  up  the  lower  pole  of -the  ti:'>itrous  tumor,  is  freed  from 
the  anterior  wall  of  the  trachea  by  blunt  dissection  and 
secured  with  two  lio~aturcs,  between  which  the  isthmus  is 
divided.  In  order  to  avoid  injurino^  the  recurrent  laryn- 
geal nerve  in  the  process  of  detachint»:  the  thyroid  gland 
from  the  lateral  wall  of  the  trachea  Kocher  divides  the 
structure  of  the  goiter  parallel  with  the  trachea  and  in 
this  way  leaves  behind  a  portion  of  the  capsule  of  the 
goiter  as  a  protection  against  injury  of  the  nerve  (resection 
of  goiter). 


302  OPERATIVE  SUBGEEY. 

III.  OPERATIONS  ON  THE  TRUNK  AND 
THE  PELVIS. 

Paracentesis  Thoracis,  Thoracotomy.  —  The  thorax  is 
opened  by  puncture  or  by  incision  wlien  the  presence  of 
accumulations  of  fluid  in  the  pleural  cavity  gives  rise  to 
threatening  symptoms  by  reason  of  either  their  quantity 
or  their  character.  In  general  the  statement  may  be  ac- 
cepted that  serous  and  hemorrhagic  elFusions  are  to  be 
treated  by  puncture,  and  purulent  exudates  on  the  other 
hand  by  incision.^  Either  operation  is  therefore  always 
preceded  by  exploratory  a.spiration  of  the  pleural  contents 
by  means  of  a  hypodermic  or  similar  syringe.  The  ope- 
ration of  thoracocentesis  is  performed  by  the  introduction 
of  8  trocar  and  cannula  between  two  ribs  into  the  pleural 
space,  either  permitting  the  fluid  simply  to  escape,  or 
aiding  its  removal  by  means  of  aspiration.  If  the  cannula 
is  so  constructed  that  the  aspiration  of  air  can  be  avoided 
during  the  removal  of  the  trocar,  the  first  method  of  pro- 
cedure meets  all  requirements.  Billroth's  cannula  is 
provided  with  a  lateral  branch  for  the  escape  of  the  fluid, 
whicli  can  be  controlled  by  a  cock.  To  this  branch  a  rub- 
ber tube  of  suitable  length  is  attached.  The  branch  of 
the  cannula  in  which  the  stilet  is  introduced  is  also  pro- 
vided with  a  cock,  which  is  closed  after  the  stilet  has  been 
removed.  The  patient  is  placed  in  the  sitting  posture 
with  the  trunk  bent  somewhat  forward.  The  trocar  is 
introduced,  except  in  the  presence  of  a  sacculated  efPusion, 
at  the  most  marked  convexity  of  the  ribs  in  the  fourth, 
fifth,  or  sixth  intercostal  space,  and  close  to  the  upper 
border  of  the  lower  rib.  The  operator  marks  accurately 
the  point  of  introduction  with  the  index-finger  of  his  left 

1  If  a  hemorrhagic  collection  is  very  extensive  and  the  life  of  the 
patient  is  seriously  threatened,  it  is  proper  to  open  the  thorax  after  rib-re- 
section and  endeavor  to  arrest  the  hemorrhage  by  ligatures,  by  suture- 
ligatures,  by  packing  a  small  pulmonary  wound,  or  by  filling  the  pleura 
with  sterile  gauze,  to  secure  a  point  of  counter-pressure,  and  packing 
iodoform-gauze  directly  against  the  bleeding  lung. — Ed. 


OPERATIOy^  Oy   THE  TRVyK  AM)   THE  PELVIS.  303 

hand.  Tho  ])nnu'li  of  the  caniiula  for  the  escape  of  the 
thiid  is  chtscd.  Troear  and  caniiida  are  introdnced  verti- 
cally nntil  disappearance  of  the  resistance  of  the  thoracic 
wall  indicates  that  the  point  of  the  instrnment  has  entered 
the  })lcnral  ca\ity.  The  o]>erator  now  irras})s  the  instru- 
ment with  his  left  hand,  removes  the  trocar,  and  permits 
the  fluid  to  escape  through  the  lateral  branch  of  the  can- 
nula. The  extremity  of*  the  rubber  tube  dips  into  a  ves- 
sel containing:  aseptic  fluid.  The  flow  should  take  place 
steadily  antl  shjwly.  By  this  mode  of  procedure  the 
entrance  of  air  is  avoided  with  certainty. 

If  the  discharge  of  fluid  ceases  suddenly,  the  flow  can  be  facilitated  by 
changing  the  position  of  the  cannula,  if  the  obstruction  be  due  to  ap- 
proximation of  the  lung.  Occlusion  of  the  tube  by  coagula  may  be 
overcome  by  the  introduction  of  a  blunt  probe. 

The  evacuation  of  the  fluid  can  be  better  controlled 
when  with  puncture  is  conjoined  aspiration  of  the  pleural 
exudate.  In  place  of  the  trocar  and  cannula  a  sharp  hol- 
low needle  is  employed,  which  is  connected  by  means  of  a 
tube  with  the  neck  of  an  airtight  bottle  from  whose  in- 
terior the  air  is  exhausted  with  the  aid  of  a  suitable  pump 
(Dieulafoy's  aspirator).  Fluid  can  thus  be  evacuated  by 
negative  pressure  when  it  would  fail  to  flow  spontaneously 
from  the  pressure  withiu  the  pleural  cavity. 

Thoracotomi/,  opening  of  the  pleural  cavity  by  incision, 
is  indicated  when  the  pleural  exudate  is  purulent  in  char- 
acter. Unless  the  exudate  be  sacculated  or  circumscribed, 
the  incision  is  made  in  the  fifth  or  sixth  intercostal  space 
over  the  greatest  convexity  of  the  ribs.  To  avoid  injury 
of  the  intercostal  vessels  the  knife  is  introduced  close  to 
the  upper  border  of  the  rib,  dividing  the  two  layers  of 
intercostal  muscles,  the  endothoracic  fiiscia,  and  the  pleura 
throughout  the  entire  extent  of  the  incision.  By  the  in- 
troduction of  a  rubber  tube  into  the  wound  drainage  of  the 
pleural  cavity  will  be  established.  To  permit  of  more 
convenient  access  and  to  render  possible  adequate  drainage 
resection  of  from  3  to  4  cm.  of  a  rib  in  its  contin\iity  is 
recommended.     Under  these  circumstances    the  incision 


304  OPERATIVE  SURGERY. 

is  made  directly  over  the  rib,  dividing  its  periosteum 
throughout  a  distauce  of  5  or  6  cm.  The  periosteum  is 
reflected  upward  aud  downward  by  means  of  a  raspatory 
from  the  anterior  surface  of  the  rib,  and  then  with  espe- 
cial care  from  its  posterior  surface.  The  portion  of  the 
rib  thus  exposed  is  resected  throughout  the  given  extent 
by  means  of  bone-shears.  The  uninjured  pleura  is  incised, 
the  purulent  contents  permitted  to  escape,  and  drainage 
established.  If  in  the  presence  of  a  pleural  fistula  the 
empyema  cannot  be  made  to  close  on  account  of  the  rigid- 
ity of  the  thoracic  wall,  resection  of  a  series  of  ribs  is  a 
suitable  procedure  in  order  to  render  the  wall  of  the  chest 
more  yielding.  The  possibility  thus  established  of  ap- 
proximating the  parietal  and  visceral  layers  of  the  pleura 
renders  the  conditions  favorable  for  cessation  of  the  long- 
continued  aud  tedious  suppui'ative  process.  A  long,  verti- 
cal incision  exposes  the  series  of  ribs,  which  are  to  be 
subjected  individually  to  subperiosteal  resection  through- 
out an  extent  of  from  3  to  10  cm. 

Ligation  of  the  Internal  Mammary  Artery. — The  cuta- 
neous incision  is  made  in  the  third  or  fourth  intercostal 
space  from  the  border  of  the  sternum  outward  for  a  dis- 
tance of  4  or  5  cm.  The  skin,  the  subcutaneous  connec- 
tive tissue,  the  pectoralis  major,  and  the  internal  inter- 
costal muscle  are  divided  throughout  the  extent  of  the 
incision.  Lying  in  front  of  the  pleura,  in  the  angle 
between  the  rib  and  the  sternum,  is  the  internal  mammary 
artery,  which  follows  the  axis  of  the  body  and  is  accom- 
panied by  two  veins.  The  vessel  can  readily  be  isolated 
from  the  loose  connective  tissue.  Esmarch  makes  a  longi- 
tudinal incision  alongside  the  sternum  and  enlarges  the 
field  of  operation  by  resection  of  a  costal  cartilage. 

Removal  of  the  Mammary  Gland. — The  mammary 
gland  is  removed  completely  Avhen  the  seat  of  a  malig- 
nant neoplasm.  AYith  the  gland  are  also  removed  en 
masse  the  chain  of  lymph-glands  extending  from  it  to 
the  axillary  cavity  and  the  mass  of  axillary  lymphatic 
glands  in   conjunction  Avith   the  fat  by  which   they  are 


OPKIiATloys  OX  THE  TJiUyK  ASD   Till-:  PELVIS.  305 

surroiiiKU'd.  The  patient  CK'cupics  tlic  dorsal  (kfuliitus, 
with  tilt'  muK  r  part  of  tlu*  body  elevated  and  the  arm  on 
the  atfectcd  side  alxluetetl  somewhat  alx)ve  the  horizontal 
line.  Two  ineisions,  iorminj;  an  oval  with  its  longitudi- 
nal axis  prising  i'roni  alxive  and  without  downward  and 
inwaixl,  are  made  from  the  free  border  of  the  peetoralis 
major  musele  to  the  ensiform  eiirtilage,  ineluding  the  mam- 
millarv  areola  (Fig.  1S§).  The  healthy  skin  is  disseeted 
free  from  the  subjaeent  structures  and  when  the  margin 


Fig.  188. — Amputation  of  the  breast :  cutaneous  incision. 


of  the  gland  has  been  reached  this  is  removed  from  the 
thoracic  wall  Avith  the  upper  layers  of  the  peetoralis 
major,  or  in  conjunctir>n  with  the  whole  muscle.  The 
separation  is  effected  throughout  the  entire  extent  of  the 
mammary  irland  with  the  exception  of  the  pole  directed 
toward  the  axilla.  Then  the  axillary  fat  and  the  con- 
tained lymphatic  glands  are  removed  en  masse.  The 
group  of  glands  remains  in  connection  with  the  breast. 
From  the  upper  pole  of  the  oval,  which  is  directed  toward 
the  axillarv  cavitv,  an  incision  is  made  alonj;  the  free 

20 


306  OPERATIVE  SURGERY. 

border  of  and  down  to  the  pectoralis  major  muscle.  The 
lower  margin  of  the  wound  is  retracted  downward,  and 
the  pectoralis  major  upward.  Beginning  at  the  pectoralis 
major,  the  mass  of  fat  is  detached  by  means  of  anatomic 
forceps  from  the  group  of  large  vessels  and  nerves.  Of 
especial  importance  in  this  connection  is  the  large  axillary 
vein,  which  lies  uppermost  and  whose  separation  is  to  be 
effected  with  especial  care.  As  the  dissection  progresses 
it  will  become  necessary  to  divide  between  t^^o  ligatures 
the  trunks  of  arteries  and  veins  passing  between  the 
groups  of  glands  drawn  downward  and  the  large  vessels. 
After  the  glands  have  thus  been  separated  from  the  large 
vessels,  the  subscapularis  and  latissimus  dorsi  muscles  are 
yet  to  be  dissected.  The  connections  between  the  group 
of  glands  and  these  muscles  are  quickly  divided  with  the 
knife,  when  the  entire  mass  of  axillary  fat  may  be  removed 
en  masse  in  conjunction  with  the  breast.  Under  some  cir- 
cumstances the  subscapular  artery  and  vein,  the  posterior 
circumflex  artery  and  vein,  or  the  long  thoracic  artery  and 
vein  may  require  ligation.  Klister  has  called  attention  to 
the  importance  of  protecting  the  long  thoracic  nerve  from 
injury.  If  it  prove  impossible  to  free  the  axillary  vein, 
it  often  becomes  necessary  to  sacrifice  a  portion  of  this 
vessel.  After  the  application  of  ligatures  the  vein  is 
resected  throughout  the  necessary  extent  and  removed 
together  witli  the  glands.  For  the  removal  of  infiltrated 
glands  from  the  infraclavicular  and  supraclavicular  fossae 
accessory  operations  are  necessary.  Transverse  division 
of  the  pectoralis  major  and  minor  muscles  will  render  the 
infraclavicular  fossa  conveniently  accessible.  For  the  re- 
moval of  supraclavicular  glands  either  an  incision  is  made 
as  in  ligation  of  the  subclavian  artery  above  the  clavicle, 
or  the  clavicle  is  divided  temporarily  at  the  junction  of  its 
middle  and  outer  thirds.^ 

^  The  operation  of  Halsted  is  extensively  employed  in  the  United 
States.  In  this  operation  the  surgeon  removes  the  entire  breast  and  the 
skin  over  it,  the  axillary  glands  and  fat,  and  the  pectoral  muscles.  The 
mass  is  removed  in  one  piece.  In  many  cases  the  subclavicular  glands 
and  fat  are  also  removed. — Ed. 


OPERATIONS  ON  THE  TRUNK  AND   THE  PELVIS.   '607 

Abdominal  Puncture,  Paracentesis  Abdominalis. — The 
aUlomiiKil  cavity  may  he  opciu'd  by  puiK'tiire  to  eticct 
cvaouatioii  ot  Hiiid  accuinulations,  either  free  within  the 
peritoneal  cavity,  or  saeenlated,  or  contained  within  cysts. 
[f  the  Huid  be  free,  the  ]i()int  of  ^lonro,  that  is,  a  ])oint 
midway  between  the  uml)ilicii>  and  the  left  anterior  iliac 
spine,  is  as  a  rule  seleeted  as  the  situation  for  puncture. 
Trzebizky  has  demonstrated  tliat  in  a  small  })roporti()n  of 
eases  the  epigastric  artery  or  one  of  its  branches  may  be 
injured  in  performino  puncture  by  this  method.  If,  liow- 
ever,  the  troear  is  introduced  into  the  outer  half  of  the 
line  between  the  umbilicus  and  the  superior  iliac  spine, 
the  possibility  of  this  unpleasant  occurrenee  is  safely 
avoided.  The  reeommendation  to  make  the  puneture 
upon  the  left  side  of  the  abdomen  is  not  of  primary  ira- 
portanee.  If  the  liver  be  enlarged,  the  puncture  will  be 
preferably  made  upon  the  left  side.  Enlargement  of  the 
spleen  of  an}'  considerable  degree  will  justify  making  the 
puncture  upon  the  right  side.  The  puncture  may  further 
be  made  in  the  linea  alba,  midway  between  the  umbilicus 
and  the  symphysis  pubis.  The  selection  of  the  point  of 
puncture  in  the  presence  of  cysts  and  of  sacculated  exu- 
dates will  be  o'overned  bv  the  situation  of  the  accumula- 
tion  of  fluid. 

In  performing  puncture  of  the  abdomen  a  straight 
trocar  and  cannula  with  a  lateral  branch  are  employed. 
The  patient  occupies  a  partial  lateral  position  or  the  upper 
portion  of  the  body  is  elevated.  Before  the  trocar  is  in- 
troduced it  should  be  determined  by  careful  percussion 
that  the  mtestine  is  not  adherent  to  the  abdominal  wall  at 
the  |X)int  where  the  puncture  is  to  be  made.  The  index- 
linger  of  the  left  hand  is  placed  at  the  point  of  puncture, 
and  the  trocar  is  introduced  vertically  through  the  ab- 
dominal walls,  then  grasped  Avith  the  left  hand,  while  the 
right  removes  the  troear.  By  means  of  a  tube  attached 
to  tiie  lateral  branch  of  the  cannula  the  fluid  is  permitted 
to  esca[)e  slowly  into  a  suitable  receptacle.  If  the  intra- 
abdominal pressure  falls,  the  escape  of  the  fluid  is  favored 


308  OPERATIVE  SURGERY. 

by  compression  of  the  abdomen  with  the  hand  or  by 
tightening  a  many-tailed  bandage  around  the  abdomen. 
It  is  an  old  rule  never  to  permit  the  escape  of  all  of  the 
fluid  contained  within  the  abdominal  cavity.  The  trocar 
is  therefore  removed  at  a  time  when  a  certain  amount  of 
fluid  is  yet  present,  and  the  wound  is  closed  with  a  suit- 
able dressing. 

Celiotomy. — Opening  of  the  abdominal  cavity  through 
incision  of  the  abdominal  walls  is  designated  celiotomy. 
This  procedure  is  a  preliminary  one  in  the  performance 
of  intraperitoneal  operations  of  all  kinds.  The  abdominal 
incisions  are  sometimes  made  longitudinally,  sometimes 
more  or  less  obliquely,  and  sometimes  even  transversely. 
Longitudinal  incisions  are  made  either  in  the  linea  alba, 
or  along  the  outer  border  of  the  rectus  abdominis  muscle. 
In  the  epigastrium  and  the  hypogastrium,  both  oblique 
incisions  parallel  with  the  costal  margin,  or  with  Poupart's 
ligament,  and  longitudinal  and  transverse  incisions  are 
employed.  The  incision  into  the  linea  alba  is  indicated 
in  the  presence  of  large  formations  occupying  the  abdomi- 
nal cavity.  The  incision  is  made  below  the  umbilicus 
when  the  pelvic  organs  are  the  object  of  attack.  Through 
the  epigastrium  access  is  gained  to  the  stomach,  or  upon 
the  right  side  to  the  liver  and  the  gall-bladder.  An 
incision  is  made  into  the  hypogastrium  when  it  is  intended 
to  reach  upon  the  right  the  cecum  or  the  vermiform  appen- 
dix, and  upon  the  left  the  descending  colon  or  the  sigmoid 
flexure  (Fig.  190).  In  the  performance  of  intraperitoneal 
operations  the  patient  is  either  placed  horizontally  or  the 
body  is  placed  upon  an  inclined  plane  with  the  head  at 
the  lowest  and  the  pelvis  at  the  highest  level  (Trendelen- 
burg's position,  Fig.  189).  This  position  affords  a  clear 
view  of  the  arrangement  of  the  pelvic  organs  after  the 
abdominal  cavity  has  been  opened,  the  intestmes  sinking 
down  toward  the  epigastrium  in  the  concavity  of  the 
diaphragm.  The  position  therefore  permits  careful  in- 
spection of  the  abdominal  viscera  and  protects  the  intes- 
tines from  extrusion  during  the  course  of  the  operation. 


OPERATIONS  ON  THE  TRUNK  AND  THE  PELVIS.  309 

3fo(h'  of  M((hi)i(/  the  Tncision  tlwoiif/h  the  AhdouiiiKd 
WalU. — Throiiiili  the  liiica  alha,  as  in  other  portions  of* 
the  abdominal  wall,  dissection  is  effected  layer  by  layer 
with  the  scali)el.  The  skin  and  the  subcntaneous  con- 
nective tissue  are  divided  and  access  is  oaincd  to  the  dense 
fibrous  U])per  layer  of  the  sheath  of  the  rectus  muscle  or 
between  the  two  rectus  muscles.  As  a  rule,  the  median 
borders  of  the  recti  muscles  are  exposed  witliin  the  wound. 
After  division  of  the  posterior  layer  of  the  sheath  of  the 
rectus  a  layer  of  loose  connective  tissue  comes  into  view, 
and  in  obese  persons  a  layer  of  fat  often  of  considerable 


Fig.  189.— Trendelenburg's  position. 

extent  lying  directly  upon  the  peritoneum.  All  of  the 
tissues  are  carefully  divided  by  blunt  dissection  with  two 
pairs  of  forceps.  A  fold  of  parietal  peritoneum  is  ])icked 
up  and  opened  at  one  ])oint  and  the  incision  is  enlarged 
above  and  below  throughout  the  extent  of  the  superficial 
wound  by  means  of  scissors  or  a  blunt-pointed  knife. 
Longitudinal,  oblirjue,  or  transverse  incisions  in  the  epi- 
gastrium extend  also,  like  those  in  the  hy})ogastrium, 
successively  through  the  layers  of  the  abdominal  muscles 
to  the  subserous  fiit  and  the  peritoneum.  A  fold  of  the 
parietal  peritoneum  is  picked  up  with  two  pairs  of  forceps 


310 


OPERATIVE  SURGERY. 


and  snipped  with  scissors,  and  the  incision  is  enlarged  in 
the  manner  already  described.  The  closure  of  the  ab- 
dominal wall  should  be  firm  and  resistant ;  the  resulting 
cicatrix   should  display  no  tendency  to  ectasis  and  the 


Fig.  190. — Ahdoniinal  incisions:  «,  lonijitudiniil  incision  for  opera- 
tions on  tliestoniacli ;  h,  incision  for  ujastrostoiny  ;  c,  incision  for  oi)erat.ions 
on  the  gall  bladder;  (L  incision  for  epicystotoniy ;  c,  incision  for  ligation 
of  the  external  iliac  artery;  /,  incision  for  colotomy  ;  g,  incisions  for  ex- 
posure of  the  cecum  and  the  vermiform  appendix. 

formation  of  ventral  hernia.  Suture  of  the  wound  should 
be  eftected  with  silk  or  absorbable  material  introduced  in 
tiers.  In  the  linea  alba  the  deepest  row  of  sutures  in- 
cludes the  peritoneum  only,  care  being  taken  that  smooth 


OPERATIONS  ON  STOMACH  AND  INTESTINES.      311 

serous  surfacos  arc  brought  iu  approxiuiatiou.  Tlio  second 
row  of  sutures  includes  the  rectus  niusch' togetlicr  with  its 
anterior  tii)rous  sheath;  several  deep  sutures  secure  the 
approximation  of  the  muscles;  more  superticial  ones  pass- 
ing through  the  anterior  sheath  a})proxiniate  accurately 
the  a})(»neuroses.  The  most  superiicial  layer  of  sutures 
unites  the  skin  in  the  customary  manner.  In  the  same 
way  abdominal  wounds*  in  other  situations  are  closed  by 
three  tiers  of  sutures.  The  deepest  row  unites  the  peri- 
toneum, the  middle  the  muscle  and  the  aponeurosis,  and 
the  upper  the  skin. 

Operations  on  the  Stomach  and  the  Intestines. 
— The  Establishment  of  Gastric  and  Intestinal  Fistulse. — 
In  general  the  operation  consists  in  bringing  the  selected 
portion  of  stomach  or  bowel  out  of  the  wound  after  celi- 
otomy and  uniting  the  parietal  peritoneum  at  the  margins 
of  the  abdominal  wound  throughout  a  sufficient  extent 
with  the  visceral  peritoneum  of  the  stomach  or  intestine 
by  means  of  interrupted  or  continuous  sutures.  The  stom- 
ach or  bowel  is  opened  either  at  once,  the  gastric  or 
intestinal  mucous  nieml)rane  being  united  to  the  skin,  or 
in  the  course  of  several  days,  after  the  abdominal  cavity 
has  been  closed  through  the  formation  of  adhesions 
throughout  the  extent  of  the  wound.  The  method  of 
operation  is  subject  to  various  modifications  at  different 
portions  of  the  gastro-intestinal  tract. 

The  Formation  of  a  Gastric  Fistula ;  Gastrostomy. — The 
formation  of  a  gastric  fistula  is  indicated  in  the  presence 
of  imj)ermeable  constriction  of  the  esophagus : 

(a)  In  consequence  of  the  presence  of  neoplasms ; 

(h)  In  consecjuence  of  cicatricial  stricture;  as  well  as 
for  the  introduction  of  nourishment  into  the  stomach  and 
for  purposes  of  dilating  deep-seated  strictures  through  the 
wound. 

The  stomach  is  reached  by  division  of  the  abdominal 
\vall  in  the  left  epigastric  region.  The  cutaneous  incision 
is  made  either  parallel  with  the  left  costal  margin  or 
vertically  through  the  rectus  abdominis  muscle  close  to 


312  OPERATIVE  SURGERY. 

Plate  19. 

Gastrostomy.— Suturing  one  portion  of  the  anterior  wall  of  the  stom- 
ach into  the  wound  in  the  abdominal  wall.  The  serous  margin  of  the 
wound  is  united  with  the  serous  layer  of  the  stomach  by  means  of  a 
continued  suture. 

Colostomy.— A  loop  of  the  sigmoid  flexure  has  been  drawn  forward 
and  fixed  in  the  wound. 


its  outer  border.  In  the  first  instance  the  incision  begins 
a  thum])'s  breadth  to  the  left  of  the  apex  of  the  ensiform 
cartilage  and  passes  ont^vard  and  downward  for  a  distance 
of  6  or  8  cm.  some  2  cm.  from  the  costal  margin.  The 
peritoneal  cavity  is  opened  throughout  the  extent  and  in 
the  line  of  the  cutaneous  incision,  and  a  small  portion  of 
the  stomach  is  brought  into  the  wound. 

The  stomach  may  be  recognized  by  the  characteristic  radiation  of  the 
vessels  from  the  greater  and  lesser  curvatures.  The  walls  of  the  stom- 
ach are  thicker  than  those  of  the  small  intestine:  and  the  organ  is  to 
be  distinguished  from  the  large  intestine  by  the  absence  of  sacculation. 
The  stomach  is  most  readily  reached  by  grasping  a  portion  of  the  great 
omentum  and  following  it  from  the  periphery  toward  the  greater  curva- 
ture. 

The  portir)n  of  strmiach  brought  into  the  wound  is 
suspended  in  position  by  means  of  two  fixation-sutures 
that  do  not  penetrate  its  lumen.  The  parietal  peritoneum 
is  then  closely  united  to  this  portion  of  the  stomach  with 
a  continued  suture,  including  not  only  the  thin  serous 
layer,  but  al.-r^o  the  sul>.<erous  tissues  of  both  the  abdomi- 
nal wall  and  the  stomach,  thus  increasing  the  firmness  of 
closure  (Plate  19). 

The  opening  into  the  stc)mach  can  be  made  at  once  or 
after  an  interval  of  several  days.  If  made  at  once,  an 
incision  is  made  into  the  wall  of  the  stomach  with  scissors 
in  the  line  of  the  cutaneous  wound,  and  the  mucous  mem- 
brane is  united  with  the  skin.  \^  an  interval  be  per- 
mitted to  elapse  betrN'een  the  making  of  the  cutaneous 
incision  and  the  opening  of  the  stomach,  the  organ  is 
entered  with  the  Paqueliu  cautery  and  a  drainage-tube  is 
introduced    into    the    opening   thus    made.     The   gastric 


Tab.    19. 


^m^ 


<^ 


i.iin.An.si.  /-.  npiauiaui,  Mun 


OPERATIONS  ON  STOMACH  AND  INTESTINES.      313 

fistula  tluis  loniuMl  is  ailcndcd  witli  certain  objections,  as, 
opcninji;  directly  ii[)oii  the  skin,  it  possesses  not  the  sl:<;htest 
dejj^ree  of  continence,  the  nntritive  Huids  introduced  es- 
capino^  in  the  erecrt  posture,  while  the  a<rid  <rastric  juice 
excoriates  the  surrounding  skin.  Anion<j^  numerous  sug- 
gestions to  overcome  these  disadvantages  some  of  the 
most  useful  arc  herewith  described. 

Witzel  forms  a  canal  by  uniting  with  suture  two  paral- 
lel longitudinal  folds  of  the  portion  of  stomach  with- 
drawn. A  suitably  large  portion  of  the  wall  of  the  stom- 
ach is  brought  forward  and  fixed  in  the  wound.  Two 
folds  of  the  stomach  are  raised  and  united  by  suture  over 
a  rubber  tube  after  the  lower  extremity  of  the  tube  has 
been  pushed  into  the  stomach  through  as  small  an  open- 
ing as  possible  in  the  gastric  parietes.  The  canal  can  be 
]n'olonged  for  any  distance  by  the  introduction  of  addi- 
tional sutures.  Witzel  makes  it  from  4  to  8  cm.  long. 
The  rubber  tube  thus  enters  the  stoma(;h  in  the  same  way 
as  the  lower  (\xtremity  of  the  ureter  enters  the  bladder  and 
the  stomach  remains  continent  through  the  establishment 
of  this  oblique  fistula,  the  canal  formed  being  subjected  to 
a  certain  amount  of  compression  from  the  stomach. 

Frank  makes  the  cutaneous  incision  parallel  with  the 
costal  arch,  and  after  dividing  the  peritoneum  withdraws 
the  stomacli  for  a  distance  of  3  or  4  cm.  and  sutures  it 
into  the  wound,  a  thread  being  introduced  into  its  summit. 
A  second  incision,  1.5  cm.  long,  is  made  through  the  skin 
along  tile  (!ostal  arch  about  3  cm.  above  the  first.  Between 
the  two  incisions  tiie  skin  is  freed  and  the  ]K)rtion  of 
stomach  withdrawn  is  ]iassed  beneath  the  bridge  of  skin 
thus  formed  and  fixed  into  the  upper  wound  and  its  sum- 
mit incised.  The  first  incision  is  then  closed  by  suture. 
The  fistulous  opening  lies  above  the  level  of  the  stomach 
and  can  be  readily  c()m])ressed  l^y  the  overlying  looplike 
l)ridge  of  skin. 

Enterostomy  (Formation  of  an  Intestinal  Fistula)  and 
Preternatural  Anus. — A  fistulous  ojx'iiing  into  the  intestine 
through  the  abdominal  wall  is  formed  when  a  provisional 


314  OPERATIVE  SURGEBY. 

means  of  escape  for  the  intestinal  contents  is  desired  in 
the  presence  of  intestinal  obstrnction  withont  a  definite 
knowledge  as  to  the  seat  thereof.  A  short  incision  is 
made  throngh  the  skin  over  and  in  the  conrse  of  Poiipart's 
ligament.  The  muscles  are  next  divided  and  the  peri- 
toneum incised.  If  distended  large  intestine  comes  into 
view,  it  is  drawn  forward,  or,  if  on  the  contrary,  a  loop 
of  distended  small  intestine  present  in  the  Avound,  it  is 
sutureel  through  a  small  extent  to  the  parietal  peritoneum. 
If  possible,  the  opening  into  the  intestine  should  con- 
stitute a  second  stage  of  the  operation,  after  the  peritoneal 
cavity  has  been  walled  oif  by  means  of  adhesions. 

The  formation  of  a  preternatural  anus  becomes  neces- 
sary when  it  is  desired  to  furnish  a  constant  channel  of 
discharge  for  the  intestinal  contents  through  a  fistula. 
The  artificial  anus  is  most  commonly  formed  in  the  de- 
scending colon  or  the  sigmoid  flexure  (cohsfomi/)  when  the 
lumen  of  the  rectum  is  obliterated  by  a  neoplasm,  or  by 
cicatricial  narrowing.  The  descending  colon  is  exposed 
through  the  peritoneal  cavity.  The  cutaneous  incision  is 
made  in  the  left  hypogastric  region  three  or  four  fingers' 
breadth  above  and  in  the  direction  of  Poupart's  ligament. 
After  the  peritoneal  cavity  has  been  opened  a  loop  of  the 
sigmoid  flexure,  recognizable  by  its  longitudinal  bands,  as 
well  as  its  sacculation,  is  l)rought  forward.  At  about  the 
middle  of  the  loop,  close  to  the  intestinal  attachment  of 
the  mesentery,  a  strip  of  sterilized  gauze  is  passed  through 
a  slit  in  the  mesentery,  so  that  the  loop  of  intestine  in  a 
measure  rides  upon  the  gauze.  To  prevent  the  falling 
back  of  the  bowel  the  serous  layer  of  the  abdominal 
wound  may  be  united  by  several  sutures  with  the  serous 
layer  of  the  intestinal  loop  (Plate  19).  At  a  second  sit- 
ting the  loop  of  colon  is  divided  transversely  upon  its 
convexity  by  means  of  the  Paquelin  cautery  at  a  point 
opposite  its  mesenteric  attachment.  This  incision  is  pro- 
gressively enlarged  in  the  course  of  eight  or  ten  days, 
until  it  reaches  the  mesenteric  attachment,  so  that  finally 
both  portions  of  intestinal  lumen  lie  side  by  side. 


OPERATIONS  ON  STOMACH  AND  INTESTINES.     315 

Jcjjinosfowy,  tlio  formation  of  a  fistula  tliroii^h  the 
jejimuni,  is  indicated  wlicn  nonrishnient  through  the 
stomach  has  l)cc(>mc  impossihk';  for  instance,  after  ero- 
sion or  corrosion  of  the  stomacli  ;  also  when  the  stomach 
is  the  scat  of  a  new-formation,  whose  extent  forl)ids  either 
its  removal  or  gastro-enterostomy.  The  incision  is  made 
in  the  linea  alba,  between  the  umbilicns  and  the  sym- 
physis pubis.  After  the'  peritoneum  has  been  divided  the 
transverse  colon  is  brouoht  forward  at  the  attachment  of 
the  greater  omentum  and  reflected  upward.  The  duodeno- 
jejunal flexure  appears  at  the  root  of  the  mesentery.  One 
of  the  up])ermost  loops  of  jejunum  that  ean  be  readily 
drawn  into  the  wound  is  brought  forward  and  fixed  in  the 
wound  by  means  of  seroserous  sutures.  The  intestinal 
loop  is  opened  either  after  the  lapse  of  several  days,  or, 
Ix'tter,  at  once,  with  the  establishment  of  an  oblique 
fistula  by  the  method  of  AYitzel.  The  nourishment  of  the 
patient  ean  be  effected  without  difficulty  through  the  rub- 
ber tube.  As  the  oblique  fistula  closes  accurately  bile 
and  pancreatic  secretion  are  not  lost. 

Resection  of  the  Bowel. — It  has  been  established  clinic- 
ally that  considerable  portions  of  the  intestine  (two  meters 
and  more,  Kocher)  can  be  removed  by  resection  without 
detriment.  After  the  resection  has  been  effected  the 
continuity  of  the  bowel  can  be  restored  by  means  of  cir- 
cular suture  of  the  stunq^s,  or  these  may  be  brought  out 
of  the  abdominal  wound  and  an  intestinal  fistula  or  pre- 
ternatural anus  established.  Resection  of  the  bowel  is 
undertaken  : 

(1)  In  the  presence  of  injuries  of  the  intestine; 

(2)  In  the  presence  of  gangrene  of  the  bowel ; 

(3)  In  the  presence  of  neoplasms  ; 

(4)  In  the  presence  of  stenosis  of  the  bowel ; 

(5)  For  the  cure  of  intestinal  fistulfe. 

The  portion  of  intestine  intended  for  resection  must  be 
detached  from  its  surroundings,  so  that  it  can  be  brought 
out  of  the  abdominal  w^ound.  The  intestine  is  closed  by 
means  of  either  clamps  or  pressure  with  the  fingers  or 


316  OPERATIVE  SURGERY. 

strips  of  sterilized  gauze  tightened  and  tied.  The  con-, 
tents  of  the  bowel  should  have  been  furced  backward  and 
forward  before  the  intestine  is  incised.  The  division  of 
the  bowel  is  effected  with  scissors.  The  plane  of  division 
should  be  so  made,  according  to  the  suggestion  of  Kocher, 
that  a  greater  portion  of  bowel  is  removed  from  the  con- 
vexity than  from  the  mesenteric  attachment,  as  by  this 
means  the  circular  vessels  of  the  bowel  are  less  exposed 
to  injury.  The  mesentery  is  ligated  in  successive  portions 
and  divided  transversely  at  its  attachment  to  the  bowel, 
or  excised  in  the  form  of  a  wedge  whose  base  is  formed 
by  the  resected  bowel  and  imited  in  a  linear  direction. 
After  the  mucous  meml^rane  projecting  from  the  divided 
surfaces  has  been  dried  with  sterile  gauze  circular  union 
of  the  lumen  of  the  two  portions  of  bowel  may  be  pro- 
ceeded with.  If  the  lumen  of  the  two  portions  of  bowel 
is  unequal,  the  smaller  is  divided  obliquely,  so  that  the 
cut  surface  is  elliptic  in  shape. 

For  the  union  of  transversely  divided  bowel  after  resec- 
tion, as  well  as  in  the  formation  of  anastomoses,  either 
the  intestinal  suture  or  Murphy's  anastomotic  button  may 
be  employed.  The  method  of  applying  the  intestinal  su- 
ture has  already  been  described  at  page  53.  Murphy's 
button  renders  possible  rapid  effectuation  of  accurate 
union  of  divided  intestinal  lumen,  as  well  as  the  estab- 
lishment of  anastomoses  between  portions  of  the  intestinal 
tract.  This  ingenious  device  consists  of  two  capsules 
made  of  light  sheet-iron  and  nickel-plated  and  provided 
Avith  a  hollow  cylinder  internally  and  a  slight  shoulder 
externally  (Plate  20),  which  can  be  readily  pushed  the 
one  into  the  other  with  the  lingers,  when  by  reason  of  a 
clamp-like  arrangement  they  remain  thus  in  secure  appo- 
sition. The  transversely  divided  portions  of  intestine,  or 
the  slits  made  in  the  establishment  of  anastomoses,  are 
picked  up  by  continued  sutures  passing  through  all  of  the 
layers  of  the  intestinal  wall,  which  are  tied  after  the  intes- 
tine has  been  brought  over  the  respective  half  of  the  but- 
ton.    After  the  second  portion  of  the  intestine  has  been 


OPERATIONS  ON  STOMACH  AND   INTESTINES.     317 

similarly  treated  the  two  halves  of  the  button  are  pushed 
one  into  the  other  and  elanipcd  Ix'tween  the  tin<i;er.s  (Plate 
20).  In  ap])roxiinating  the  })arts  of  the  button  the  pro- 
lapse of  small  portions  of  the  mueous  membrane  in  the 
interval  between  the  segments  is  to  be  avoided.  Such  por- 
tions of  intestine  may  require  approximation  by  means  of 
Lembert's  seroserous  sutures.  The  intestine  is  thus  ad- 
justed with  broad  surfa'ces  of  serous  membrane  in  appo- 
sition. The  small  openings  in  the  sides  of  the  button 
serve  as  an  outlet  for  the  escape  of  secretion  from  the 
included  portion  of  Ijowel,  while  intestinal  contents  and 
gas  can  escape  through  the  larger  central  opening.  When 
the  clamped  portions  of  the  intestine  are  necrosed,  at  the 
end  of  one  or  two  weeks,  firm  iniion  of  the  bowel  will 
have  taken  place.  The  button  is  then  freed  and  escapes 
with  the  intestinal  contents.  The  technic  of  this  mode 
of  intestinal  union  is  exceedingly  simple  and  the  results, 
according  to  the  statistics  of  xVmerican  surgeons,  are 
admirable. 

Murphy's  reports  with  regard  to  the  success  of  his  method  are,  as  W. 
Mayer  states,  almost  incredible,  but  they  are  in  strict  accord  with  the 
facts.  The  union  of  the  bowel,  after  resection,  or  after  the  performance 
of  gastro-enterofitomy  or  cholecystenterostomy,  can  be  accurately  etiected 
in  the  course  of  a  ft^w  minutes.  The  experience  of  German  surgeons  also 
testifies  to  the  utility  of  Murphy's  method. 

Exclusion  of  Intestine  ;  Entero- anastomosis. — If  in  the 
presence  of  obstructive  tumors  or  of  tuberculosis  of  the 
intestine  extir])ation  of  the  diseased  portion  is  not  practic- 
able, the  jxitulousness  of  the  bowel  may  be  reestablished 
by  excluding  the  diseased  portion,  by  bringing  in  commu- 
nication a  loop  of  intestine  to  the  distal  and  one  to  the 
proximal  side  of  the  obstruction.  The  procedure  is  desig- 
nated incomplete  exclusion  of  the  bowel  (Wblfler)  if  the  ex- 
cluded portion  of  intestine  is  not  removed  ;  while  in  com- 
plete exclusion  of  the  bowel  the  diseased  portion  is  entirely 
separated  from  its  connection  with  the  bowel.  In  the 
first  mode  of  procedure  the  two  loops  of  intestine  are 
placed   side  by  side  and  union  effected  throughout  the 


318  OPERATIVE  SURGERY. 

Plate  20.— Union  of  Circularly  Divided   Intestine  by  Means 
of  the  Murphy  Button. 

Fig.  1.— rt,  h,  the  two  halves  of  the  buttou ;  c,  the  two  halves  of  the 
button  clamped  together;  d,  the  mode  of  introducing  the  sutures  for 
holding  each  half  of  the  button  in  place. 

Fig.  2.— Completed  union  of  the  intestine  by  means  of  the  Murphy 
button.     The  slit  in  the  mesentery  has  been  closed  by  linear  union. 


extent  of  the  t\yo  lateral  openings  made  by  means  of  two 
rows  of  sutures  or  of  INIurphy's  button.  In  case  of  ob- 
struction of  the  pylorus  continuity  of  the  digestive  tract 
may  be  reestablished  by  making  a  conununication  between 
the  stomach  and  a  loop  of  jejunum  {gastro-enterostomy). 
If  the  cecum  be  the  seat  of  an  obstructive,  inoperable 
tumor,  the  continuity  of  the  bowel  may  be  reestablished 
by  uniting  a  portion  of  the  ileum  with  the  adjacent  ascend- 
ing colon  (ileocolostomy). 

Salzer  has  shown  experimentally  that  the  retention 
within  the  abdomen  of  the  excluded  portion  of  bowel  is 
not  without  danger,  and  he  has  modified  the  operation 
accordingly  so  that  the  bowel  is  divided  transversely  upon 
either  side  of  the  obstruction  and  circular  union  is  effected. 
The  ends  of  the  excluded  portion  of  bowel  are  sewed  in 
the  abdominal  wound  (complete  exclusion  of  the  bowel). 

Hacker  has  enlarged  the  indications  for  entero-anastomosis  and  recom- 
mends the  operation,  in  addition  to  cases  of  inoperable  neoplasms,  also 
in  cases  of  jienetrating  injuries  of  adjacent  portions  of  bowel,  as  well  as 
in  the  treatment  of  fecal  fistulse.  Communications  between  the  bladder 
and  the  bowel  might  also  be  successfully  treated  by  means  of  exclusion 
of  the  bowel. 

Mode  of  Performing  Gastro-enterostomy. — An  incision  is 
made  in  the  liuea  alba  between  the  umbilicus  and  the 
ensiform  cartilage.  The  transverse  colon,  together  with 
the  great  omentum,  is  drawn  out  of  the  wound  and  re- 
flected upward.  In  the  transverse  mesocolon,  at  a  point 
where  it  is  in  relation  with  the  stomach,  is  made  a  slit 
whose  margins  are  attached  by  suture  to  the  serous  layer 
of  the  stomach  so  as  to  include  an  area  perhaps  as  large 
as  a  silver  dollar.     A  loop  of  the  upper  portion  of  the 


Tab.  20. 


/ 


c. 


tiy.-. 


'^I  w"^ 


/    ^     ,^    / 


\\\ 


Lull..  AiiM-  /•■  Heiaitwul.  Mancheu 


oPERATioys  rpox  Tin-:  r.iiJAiiY  APiwRArrs.   319 

jojuiuini  that  can  be  approxiinatcxl  with  the  stomach 
witlioiit  tension  is  incised,  together  with  tlie  stomach  at 
its  jx)int  of  attachment  to  the  mes(X'<>h)n,  and  nninn  of  the 
opixtsed  paits  is  ettected  either  hy  suture  or  with  the  aid 
of  the  Murphy  button.  The  first  row  of  sutures  includes 
the  entire  thickness  of  the  intestinal  and  gastric  walls,  at 
the  margins  of  the  resjx'ctive  openings.  A  row  of 
Lembert  serous  sutures  is  applied  over  the  first  row. 

Operations  upon  the  Biliar>"  Apparatus. — Beside 
abscesses  and  cvsts  of  the  liver,  tor  who-*.-  operative  treat- 
ment no  especial  rules  can  be  laid  down,  attacks  u}xjn  tlie 
biliary  apparatus  are  directed  especially  toward  the 
removal  of  calculi  and  their  sequelae.  The  surgery  of 
the  biliary  apparatus,  the  youngest  department  of  ab- 
d«)minal  surgery,  has  been  systematically  practised  only 
since  the  besrinninor  of  the  eighties.  The  cutaneous 
incisions  throuofh  which  the  transverse  fissure  of  the  liver 
is  reached  are  varied.  At  times  it  is  made  in  the  linea 
alba  between  the  umbilicus  and  the  symphysis  pubis.  At 
other  times  it  is  made  along  the  outer  border  of  the  rectus 
abdominis  muscle.  Czeruy  makes  an  anirular  incision, 
whose  vertical  arm  passes  along   the  linea  alba,  and  is 

joined  below  the  umbilicus  by  a  horizontal  incision  pass- 
ing towai\l  the  right  and  outward.  In  all  cases  after 
opening  the  peritoneal  cavity  the  right  lobe  of  the  liver 
is  reflected  upward  s<j  that  its  under  surface  is  exjx>se<l  to 
view,  tojrether  with  the  crall-bladder  and  the  transverse 
fissure.  Between  the  last  and  the  lesser  curvature  ot  the 
stomach  there  extends  a  duplication  of  the  peritoneum 
(the  lesser  omentum)  in  whose  right  free  extremity  pass 
the  large  biliary  ducts,  the  portal  vein,  and  the  hepatic 
artery  in  the  order  2"iven. 

Operations  on  the  Gall-bladder. — The  gall-bladder  is 
<»pened  by  incision  {cholecystotomy)  for  the  removal  of  gall- 
stones, and  the  evacuation  of  empyema  or  dropsy  of  the 
gall-bladder.  Incision  of  the  gall-bladder  may  be  made 
in  one  stage,  or,  after  suture  of  a  portion  of  the  viscus 
into  the  abdominal  wound,  in  two  stages.     In  operating 


320  OPERATIVE  SURGERY. 

at  a  single  sittiiiii',  after  removal  of  oaleuli  present,  the 
wound  in  the  gall-bladder  may  l^e  united  by  suture  and 
the  abdominal  Avound  be  closed  {ideal  choleci/stotomi/j 
cliolecy  steady  sin),  or  the  sutured  gall-bladder  may  be  sus- 
pended at  the  level  of  the  wound.  If  primary  suture  be 
not  imdertaken,  a  fistula  of  the  o:all-])ladder  throuu-h  the 
abdominal  wall  may  be  established  according  to  the  rules 
that  govern  intestinal  operations  (choleci/stotomt/).  With 
regard  to  the  performance  of  cholecystotomy  it  need  only 
be  said  that  after  making  the  cutaneous  incision  and  open- 
ing the  peritoneum  the  gall-bladder  should  be  brought  as 
fully  as  possible  to  the  level  of  the  wound,  where  it  is 
attached  and  held  in  position  with  sutures.  After  punct- 
ure of  the  viscus  it  is  incised  and  under  guidance  of  the 
finger  calculi  present  are  removed  with  the  aid  of  forceps 
or  a  spoon,  attention  being  given  to  the  possible  presence 
also  of  stones  in  the  cystic  duct.  The  wound  in  the  gall- 
bladder is  united  with  two  tiers  of  sutures  in  the  same 
way  as  wounds  in  the  intestines.  The  first  row  of  sutures 
includes  the  entire  thickness  of  thegidl-bladder  and  approxi- 
mates opposed  wound-surfaces.  The  second  row  consists  of 
Lembert's  serous  sutures,  and  is  intended  to  insure  perfect 
closure  of  the  wound  by  ap})roximation  of  broad  surfaces 
of  peritoneum.  In  performing  cystotomy  in  two  stages, 
as  well  as  cystostomy,  a  portion  of  the  gall-bladder 
brought  into  the  wound  is  attached  to  the  parietal  peri- 
toneum, as  in  the  operation  of  gastrostomy,  and  the  exposed 
portion  is  opened  with  the  Paquelin  cautery  after  the  lapse 
of  several  days. 

Extirpation  of  the  gall-bladder  (choleei/stectomi/)  is  indi- 
cated in  the  presence  of  neoplasms  of  this  viscus,  as  well 
as  of  gall-stones  attended  with  inflammatory  processes  in 
the  walls  of  the  gall-bladder.  The  typical  procedure  con- 
sists after  transverse  division  of  the  cystic  duct  between 
two  ligatures,  in  separating  the  gall-bladder  by  blunt  dis- 
section from  its  attachments  to  the  liver,  which  under 
favorable  conditions  can  be  readily  eifected  after  division 
of  its  serous  covering. 


OPEMXG    OF  rKIlICKCAL  ABSCESSES.  321 

Openintj^  of  the  choledooh  duct  bv  incision  (choledo- 
chofomi/)  may  \)v  noccjrsarv  for  the  removal  of  impacted 
calculi,  the  ^\ound  made  being  closed  by  suture.  In  the 
presence  of  irremediable  obstruction  of  the  choledoch 
duct,  in  consequence  of  impaction  of  a  calculus  or  of  an 
occludino;  tumor,  or  of  compression  by  lymphatic  glands, 
a  suitable  channi'l  for  the  escape  of  the  Ijile  can  be  provided 
only  by  establishing  an-  artificial  communication  between 
the  gall-bladder  and  the  bowel  (choleci/stenterostomi/,  Wini- 
warter). The  anastomosis  is  effected  in  accordance  with 
the  rules  given  in  the  description  of  entero-anastomosis 
(page  317),  with  the  aid  of  either  suture  or  the  Murphy 
button.  The  communication  is  established  between  the 
gall-bladder  and  the  jejunum  {chokcystojejunostomy),  or 
if  possible  between  the  gall-bladder  and  the  duodenum 
(cholecysfoduoflenostomy).  Artificial  communication  be- 
tween the  intestine  and  a  dilated  choleodoch  duct  on  the 
proximal  side  of  an  obstruction  also  has  been  recom- 
mended (choJedochoduodenostomy). 

Opening  of  Pericecal  Abscesses. — Resection 
of  the  Vermiform  Appendix. — If  the  al)scess  causes 
bulging  of  the  skin  above  Poupart's  ligament,  the  incision 
is  made  over  the  most  prominent  part  of  the  swelling, 
parallel  with  the  course  of  the  fibers  of  the  external 
o])lique  muscle,  pretty  much  as  in  ligation  of  the  iliac 
artery.  The  muscles  of  the  abdominal  wall  and  the 
transversalis  fascia  are  divided  layer  by  layer  and  the 
abscess  is  opened  freely.^  If  in  a  case  of  appendicitis  it 
seems  probable  that  the  removal  of  the  appendix  will  be 
necessary,  a  vertical  incision  upon  the  right  side  along  the 
outer  border  (^f  the  rectus  abdominis  muscle  is  recom- 
mended. This  incision  ])ermits  free  access  and  renders 
possible  exploration  and  removal  of  the  appendix  nnder 

^  The  incision  employed  by  McBurney  is  very  useful.  The  incision  is 
perpendicular  to  a  line  drawn  from  the  anterior  superior  iliac  spine  to 
the  umbilicus,  and  crosses  this  line  two  inches  to  the  inner  side  of  the 
spine.  The  muscles  are  separated  by  blunt  dissection.  The  fact  that 
muscle-fibers  are  not  cut  is  a  preat  safeguard  against  hernia,  because  the 
muscles  do  not  degenerate. — Ed. 

21 


322  OPERATIVE  SURGERY. 

favorable  conditions.  After  the  abdominal  cavity  has 
been  opened  the  perit'^neal  cavity  is  walled  off  from  the 
cecum  by  means  of  compresses,  and,  after  separation  of 
the  adhesions  of  the  cecum  to  neighboring  structures,  the 
exact  seat  of  the  disease  is  located.  If  an  accumulation 
of  pus  has  been  found  and  is  evacuated,  the  vermiform 
appendix  is  carefully  separated  from  its  surroundings  and 
freed  for  removal.  After  ligation  of  the  meso-appendix 
a  circular  incision  is  made  around  the  appendix  to  the 
peripheral  side  of  the  point  of  removal  through  the  serous 
membrane  and  the  muscular  layer  down  to  the  mucosa, 
wdiich  is  ligated  and  divided  transversely  to  the  distal  side 
of  the  ligature.  The  short  cuff  formed  is  reflected  upon 
the  stump,  which  is  grasped  and  inverted  into  the  lumen 
of  the  appendix.  The  margins  of  the  shallow  depression 
thus  made  are  united  by  a  row  of  Lembert's  sutures  over 
the  inverted  stump  of  tlie  appendix  (Fowler).^ 

Operations  upon  the  Genito- urinary  Organs. — 
Catheterization. — From  its  external  orifice  to  the  entrance 
of  the  bladder  the  male  urethra  consists  of  three  anatomi- 
cally and  functionally  different  parts,  viz.,  the  penile  por- 
tion, the  membranous  portion,  and  the  prostatic  portion. 
The  penile  portion  is  surrounded  by  the  corpus  spongio- 
sum, which  presents  an  enlargement  at  its  anterior  and 
posterior  extremities,  known  respectively  as  the  glans 
penis  and  the  bulb  of  the  urethra.  The  membranous 
portion,  around  which  a  sphincter  of  striated  muscular 
fibers  is  arranged,  penetrates  the  deep  transverse  perineal 
muscle  stretched  beneath  the  pubic  arch,  so  that  its  proxi- 
mal division,  together  Avith  the  prostatic  portion,  repre- 
sents the  intrapelvic  part  uf  the  urethra.  The  membra- 
nous portion  may  be  looked  upon  as  the  most  fixed  seg- 
ment of  the  urethra.  In  front  of  it  is  the  movable  pendu- 
lous portion  and  behind  it  tlie  prostatic  portion  movable 
within    slight    limits.      That  portion  of   the  urethra    in- 

^  Instead  of  forming  a  stump  and  treating  it  by  inversion,  sonu'  sur- 
geons prefer  to  remove  with  the  appendix  an  elliptical  piece  of  the  colon, 
and  then  to  close  the  colon-wound  bv  means  of  inversion-sutures. — Ed. 


OPERATlOSii    Uroy  GEMTO-URISARY  ORG  ASS.     323 


i 


191.       192.       193.         194.  195.  196. 

Figs.  191-194. — Soft  catheters  of  varying  form. 

Fig.  191. — Catheter  coude. 
Fig.  192. — Conical  and  bulb-tipped  catheter. 
Fig.  193. — Conical  and  pointed  catheter. 
Fig.  194. — Cylindrical  catheter. 

Fig.  19.5. — Massive  steel   sound  (stone-sound)  for  exploration  of  the 
bladder. 

Fig.  196.— Metallic  catheter. 


OPERATIOSS   UPON  GENITO-URINARY  ORG  ASS.     325 

eluded  between  the  external  orifiee  and  the  sphineter  of 
the  membranous  portion  is  known  as  tlie  anterior  urethra, 
tliat  portion  posterior  to  this  as  the  posterior  urethra,  a 
distinction  especially  of  clinical  significance.  The  entire 
fixed  portion  of  the  urethra,  from  the  mouth  ol  the 
bladder  to  the  bend  of  the  penis  forms  a  large  arch  with 
its  convexity  backward..  The  base  of  the  arcli  corresponds 
with  the  point  at  whicli  the  membranous  urethra  passes 
through  the  urogenital  diaphragm. 

Catheterization  consists  in  proper  instrumental  evacu- 
ation of  the  contents  of  the  bladder  throuo:h  the 
urethra.  To  effect  this  pui'pose  tubular  instruments  are 
employed,  which  are  made  either  of  soft  material  or  of 
metal,  and  are  of  varied  shape.  The  choice  of  instru- 
ments will  depend  upon  the  conditions  present  in  the 
individual  case. 

The  pliysician  in  performing  catheterization  will,  in 
accordance  with  the  symptoms  present  and  the  results  of 
external  and  rectal  examination,  form  an  idea  of  the  con- 
dition of  the  urethi-a  and  determine  accordinglv  the  selec- 
tion  of  a  suitable  instrument.  Soft  instruments,  of  vul- 
canized rubber  or  of  unpigmented  a\  oven  silk,  are  made 
of  varying  thickness  and  are  either  straight  or  bent 
slightly  at  their  vesical  extremity.  The  former  are  either 
cylindrical,  conical,  or  nodular  at  their  vesical  extremity. 

Catheters  bent  at  their  extremity  at  an  angle  (catheter 
coude)  are,  notAvithstanding  their  softness,  well  adapted 
by  reason  of  their  shape  to  overcome  certain  kinds  of  ob- 
struction, principally  dependent  upon  changed  conditions 
of  the  j)rostate. 

Rigid  instruments  made  of  metal  are  shaped  in  accord- 
ance with  the  configuration  of  the  fixed  portions  of  the 
urethra.  The  straight  distal  portion  or  shaft  ])asses  over 
into  a  proximal  portion  bent  in  conformity  with  the  curva- 
ture of  the  posterior  urethra.  In  the  introduction  of  a 
soft  flexible  catheter  the  instrument  accommodates  itself 
to  the  shape  and  the  course  of  the  urethra  and  readily 
glides  into  the  bladder.     The  rigid  instrument  is  shaped 


326 


OPERATIVE  SURGERY. 


in  accordance  with  the  curve  of  the  urethra,  altliough  the 
correspondence  is  never  complete.  By  delicacy  in  the 
manipulation  of  the  instrument  unavoidable  distortion  of 
the  tixed  portions  of  the  urethra  will  be  reduced  to  a 
minimum. 

Mode  of  Introducing  a  Soft  Catheter  tJirough  the  Urethra 
into  the  Bladder. — The  patient  lies  upon  his  back,  with 
the  pelvis  somewhat  elevated,  and  the  operator  stands  upon 
the  left  side.     The  penis  is  grasped  with  the  left  hand  and 


Fig.  197. — Method  of  introducing  a  partially  rigid  catheter. 

raised  in  such  a  way  that  the  pendulous  portion  of  the 
urethra  is  rendered  tense,  and  the  catheter  is  introduced 
into  the  urethra  and  gently  ])iished  for^vard.  The  catheter 
coude  is  so  introduced  that  its  beak  is  directed  toward  the 
upper  wall  of  the  urethra.  In  passing  the  membranous 
portion  a  sense  of  slight  r(\sistance  is  appreciated,  which 
is  overcome  by  gentle  pressure.  From  this  point  the  beak 
of  the  instrument  slips  into  the  bladder  without  further 
obstruction.  In  the  presence  of  hypertrophy  of  the 
prostate  and  of  elongation  of  the  prostatic  portion  of  the 


OPERATIOSS   UPON  GKSITO-VRISARY  ORGANS.     ^327 

urethra  tlie  catheter  niu<t  1x3  introduced  fur  a  greater  dis- 
tance, often  lip  to  its  hilt,  before  urine  flows.  After 
the  flow  of  urine  hiis  ceased  the  residual  urine  in  the 
l>ladder  will  escajx?  after  slight  withdrawal  of  the  soft 
catheter. 

Tlif  iutrodiK'tinn  of  a  rif/UJ  cofhtirr  info  the  bh/rJrlpr  is  a 
much  more  difficult   procedure,  and  its  safe  and  proper 


Fig.  198. — Introduction  of  a  rifrifl   iustrumLUt  into  the  bladder,  the  tip 
of  the  catheter  obstructed  at  the  bulbous  portion. 

execution  requires  a  certain  amount  of  skill.  In  general 
the  rule  is  to  be  ob.served  that  the  beak  of  the  instrument 
be  made  to  pass  along  the  upper  wall  of  the  urethra.  If 
the  urethra  l)e  normal,  no  difficulty  is  experienced  in  the 
operation  until  tlie  meml)ranous  portion  is  reached,  but  at 
the  junction  of  the  movable  with  the  fixed  membranous 
j)ortion  a  slight  obstruction  is  encountered  l)v  the  beak  of 
the  catheter  (Fig.  198).     Care  must  now  be  taken  to  pre- 


328 


OPERATIVE  SURGERY. 


vent  the  tip  of  the  instrument  engaging  in  the  mucou« 
meml)rane.  The  beak  most  therefore  not  deviate  from 
the  median  line,  and  with  cautious  movements  the  instru- 
ment should  be  passed  into  the  membranous  portion, 
naturally  without  any  violence.  After  the  resistance  has 
been  overcome  the  instrument  Avill  be  felt  to  enter  the 
membranous  portion  and  pass  through  the  urogenital 
diaphragm. 

From  this  point  the   catheter  in  a  normal   urethra  en- 
counters no  further  obstruction,    and  on  dopressinuf  the 


Fig.  199.^Introduction   of  a   rigid     instrument    into   the  bladder:    by 
depressing  the  shaft  of  the  catheter  its  beak  is  forced  iuto  the  bladder.' 

handle  of  the  instrument  the  tip  enters  the  bladder  with- 
out further  hindrance  (Fig.  199). 

Cdtheterizatioii  with  a  3[efa/lic  Instrument. — The  patient 
is  placed  horizontally  upon  his  })ack,  with  the  pelvis  some- 
what elevated,  and  the  operator  standing  upon   his  left 


OPERATIONS   UPON  GEyiTO-URTXARY  ORG  ASS.     329 

sicl(\  The  penis  is  grasjx'il  with  three  tinorers  of  the  left 
hand  and  the  lips  of  the  urethra  are  held  apart  V)v  means 
of  the  thumb  and  the  inilex-finger.  The  catheter  or  the 
solid  sound  is  irrasped  at  its  distal  extremity  with  the  first 
three  tiuirers  of  the  right  hand,  its  palmar  aspect  turned 
upward,  and  resting  with  the  little  finger  upon  the  middle 
line  of  the  body  (Fig.  *200j. 

The  ojX'rat<:)r  permits  the  beak  of  the  instrument  to  enter 
the  urethra  and  draws  the  penis,  with  a  certain  degree  of 


Fig.  200. — First  position  in  the  introduction  of  the  catheter. 

tension,  over  the  curve  of  the  catheter,  which  is,  at  the 
same  time  being  steadily  kept  in  the  middle  line,  orradu- 
ally  raised  until  it  reaches  a  vertical  position.  With  a 
slight  jerk  the  tip  of  the  instrument  passes  the  bulbous 
portion  and  it  yet  remains  to  enter  the  membranous  por- 
tion and  pass  the  urogenital  diaphragm  (Fig.  201). 

In  all  cases  a  sense  of  obstruction  is  encountere<:l  at  this 
point  which  is  readily  overcome  by  gentle  pressure,  while 


330  OPERATIVE  SURGERY. 

the  catheter  is  held  accurately  in  the  median  line,  and  is 
gradually  depressed  from  the  vertical  to  the  horizontal 
toward  the  lower  extremities  (Fig.  202). 

If  the  instrument  is  at  the  same  time  pushed  forward 
slightly,  its  tip  enters  the  bladder.  At  this  moment  urine 
will  escape  from  the  catheter.  AVith  the  rigid  instrument, 
as  soon  as  the  prostate  has  been  passed  and  the  bladder 
has  been  entered,  free  movements  can  be  made  with  the 
tip  of  the  instrument. 

The  method  of  introducing  the  catheter  described  is 
attended  with  difficulty  in  obese  individuals  and  in  the 
presence  of  meteorism  and  ascites.  Under  such  circum- 
stances it  seems  desiral)le  to  enter  the  catheter  at  ri^ht 
angles  to  the  axis  of  the  body,  with  the  penis  raised  ver- 
tically. In  this  position  the  instrument  is  pushed  forward 
and  at  the  same  time  rotated  in  an  arc  to  the  median  line 
and  elevated  to  a  position  until  the  tip  is  grasped  by  the 
bulbous  portion  (Fig.  203).  In  another  mode  of  pro- 
cedure the  operator  sits  before  the  patient,  who  is  placed 
in  the  position  for  the  operation  of  cutting  for  stone.  The 
catheter  is  introduced  into  the  orifice  of  the  urethra  from 
between  the  extremities  of  the  patient,  with  its  convexity 
directed  upward.  The  penis,  raised  vertically,  is  drawn 
over  the  curve  of  the  catheter  and  the  instrument  is 
rotated  through  an  arc  of  180°  t(^ward  the  right  until 
it  reaches  the  median  line.  During  the  progress  of  these 
manipulations  the  beak  of  tlie  instrument  enters  the 
urethra  to  the  bulbous  portion.  Now,  the  handle  of  the 
catheter  is  elevated  and  pushed  forward  in  the  median 
line  until  its  beak  has  passed  the  posterior  urethra  and 
entered  the  bladder. 

Ill  a  normal  urethra  an  instrument  of  considerable  weight,  as  for 
instance  a  rigid  sound  of  large  caliber  (lithotriptor),  overcomes  readily 
the  obstruction  encountered  on  the  distal  side  of  the  bulbous  urethra 
and  glides  easily,  by  reason  of  its  own  weight,  into  the  bladder,  without 
further  guidance.  The  guiding  hand  need  only  prevent  the  departure 
of  the  instrument  from  the  median  line.  In  the  presence  of  narrowing, 
however,  a  certain  amount  of  pressure  in  the  direction  of  the  urethra  is 
necessary,  in  order  to  urge  the  instrument  ouAvard  through  the  rigid 
cicatricial  tissue.     If  the  urethra  is  narrowed  in  its  deeper  portion,  or,  if 


OPERATIONS   UPON  GENITO-URINARY  ORGANS.     331 


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OPERATIONS   UPON  GENITO-URINARY  ORGANS.     333 

the  prostate  is  enlar«;ed  it  will  often  be  necessary  to  introduce  the  index- 
finger  of  the  left  hand  into  the  rectum  as  a  guide.  In  the  presence  of 
hypertrophy  of  the  prostate,  on  account  of  elongation  of  the  prostatic 
portion  of  the  urethra,  and  on  account  of  elevation  of  the  orifice  of  the 
bladder,  the  catheter  or  the  sound  must  be  introduced  for  a  greater  dis- 
tance and  be  more  greatly  depressed,  iu  order  that  the  beak  may  reach 
into  the  bladder. 

Catheters  for  introduction  into  the  female  urethra  cor- 
respond with  the  shortness  of  this  canal,  and  are  either 


Fig.  202. — Catheterization :  the  catheter  has  entered  the  mem- 
branous portion  and  has  passed  the  urogenital  diaphragm;  by  pressing 
the  handle  the  tip  enters  the  bladder. 

straight,  or  slightly  curved  at  their  extremity.  In  intro- 
ducing the  instrument  the  labia  are  separated  and  the 
handle  is  depressed  while  the  catheter  is  ])ushed  forward. 
Only  in  the  presence  of  pregnancy  or  of  tumors  of  the 
genital  oro^ans  may  the  female  urethra  be  elongated  or  dis- 
torted. The  resulting  difficulty  in  the  introduction  of  a 
catheter  is  to  be  overcome  by  the  employment  of  par- 
tially rigid  instruments,  as  in  males. 


334 


OPERATIVE  SUBGEBY. 


Retenilon-catheter. — A  catheter  may  be  permitted  to 
remain  Avithin  the  urethra  for  days  or  even  weeks.  In 
order  to  serve  its  purpose  permanently  it  must  be  suitably 
fixed  in  position.  The  introduction  of  a  retention-catheter 
into  the  urethra  permits  constant  escape  of  urine,  Avhich, 
beside,  does  not  come  in  contact  with  the  wall  of  the 
urethra.  Such  a  form  of  catheter  is  therefore  employed 
when  it  is  desired  to  place  the  bladder  at  rest,  to  secure  a 


Fig.  203. — Mode  of  introducing  the  catheter  from  the  side. 

permanent  channel  of  escape  for  the  urine  and  finally  when 
the  urethra  is  to  be  spared  irritation.  The  moderate  but 
constant  pressure  of  the  retention-catheter  softens  cica- 
trices of  the  urethra  and  exerts  a  dilating  influejice  upon 
circular  strictures,  and  for  this  reason  is  a])plicable  with 
advantage  in  the  presence  of  callous  and  cicatricial  strict- 
ures of  the  urethra.  Finally,  the  retention-catheter  is  to 
be  recommended  when  catheterization  that  must  be  fre- 


OPERATIONS   UPON  GENITO-URINARY  ORGANS.     335 

qucntly  repeated  is  attended  either  with  difficulty  or  with 
iinpk'asant  results,  sueh  as  hemorrhage  and  urinary  fever. 
The  soft  catheter  of  vulcanized  rubber  is,  as  a  rule,  em- 
ployed as  a  retention-catheter.  The  instrument  is  intro- 
duced to  a  sufficient  depth  for  the  urine;  to  escape  without 
interruption.     A  suitable  pin  is  introduced  transversely 

0 

C 


I 


B 


R 


I  I 

Fig.  204. — Fixation  of  the  retention -catheter  by  the  method  of  Dit- 
tel :  A,  B,  C,  forms  of  the  strips  of  adhesive  plaster ;  I,  II,  III,  modes 
of  applying  the  plaster   to   the   penis. 

through  the  catheter  just  in  advance  of  the  orifice  of  the 
urethra  and  its  point  broken  off.  Strips  of  adhesive 
plaster  are  prepared  in  the  manner  indicated  in  Fig.  204. 
The  square  incised  strip  with  an  opening  at  its  center  is 
applied  upon  the  glans  in  such  a  way  that  it  supj^orts  the 
pin   passing  through  the  catheter  (Fig.    204,  /).     The 


336  OPERATIVE  SURGERY. 

longer  strip  slit  in  the  middle  is  drawn  over  the  catheter, 
and  comes  to  rest  upon  the  needle,  being  made  to  adhere 
to  the  sides  of  the  penis  (Fig.  204,  //).  The  entire  ar- 
rangement is  made  secure  by  circular  turns  of  strips  of 
plaster  passing  around  the  oro^an  from  the  glans  to  the 
root  (Fig.  204,  ///). 

Puncture  of  the  Bladder. — Evacuation  of  the  bladder 
througli  suprapul^ic  puncture  is  undertaken  as  a  pallia- 
tive measure,  and  also  for  the  puqiose  of  forming  a  vesical 
fistula  through  the  abdominal  wall.  Palliative  puncture 
is  practised  in  the  presence  of  complete  retention  of  urine 
in  consequence  of  impermealjle  stricture  of  the  urethra 
when  it  is  desired  to  await  a  more  favorable  time  for  the 
introduction  of  a  sound  or  for  the  performance  of  a  radical 
operation  for  the  relief  of  the  obstruction.  For  the  pur- 
pose of  establishing  a  vesical  fistula  the  operation  is 
undertaken  (1)  in  the  presence  of  prostatic  enlargement, 
with  complete  or  incomplete  retention  of  urine,  when 
catheterization  is  attended  with  difficulty  or  is  followed 
by  hemorrhage ;  (2)  when  the  mouth  of  the  bladder  is 
obstructed  by  a  tumor  that  cannot  be  removed  by  opera- 
tive measures;  (3i  to  effect  drainage  of  the  bladder  in 
cases  of  severe  purulent  cystitis.  If  the  object  of  the 
procedure  is  only  evacuation  of  the  bladder,  the  pimcture 
is  made  with  a  thin,  so-called  exploratory  trocar.  The 
operation  is  in  itself  of  little  significance  and,  if  necessary, 
can  be  frequently  repeated.  The  patient  lies  upon  his 
back,  with  the  pelvis  somewhat  elevated.  As  the  punc- 
ture is  always  undertaken  by  reason  of  retention  of  urine, 
the  bladder  is  distended  to  the  maxinunn.  and  is  readily 
palpable  as  a  tumor  above  the  symphysis  pubis.  The 
operator  stands  to  the  right  of  the  patient,  and  marks  with 
the  tip  of  his  left  index-finger  a  point  in  the  middle  line 
just  above  the  symphysis  where  the  puncture  is  to  be 
made.  The  trocar  is  pushed  vertically  through  the  ab- 
dominal wall,  disappearance  of  the  sense  of  resistance 
indicating  that  the  point  of  the  instrument  has  entered 
the  bladder.     The  cannula  is  grasped  with  the  thumb  and 


OPERATIONS   UPON  GENITO-VRINARY  ORGANS.     337 

the  indox-tinger  of  tlie  let't  luiiul  and  the  stilet  iri  removed 
with  the  right.  After  the  urine  has  eseaped,  the  eannula 
is  removed,  its  extremity  being  closed  with  the  tip  of  the 
thumb  in  order  that  the  wound  be  not  eontaminated. 
Tlie  wound  of  puncture  invariably  heals  without  compli- 
cation. 

If  in  conjunction  with  jnmcture  a  vesical  fistula  is  to  be 
established  in  the  abdominal  wall  the  operation  is  to  be 
performed  with  the  aid  of  the  semicircularly  curved 
trocar  of  Fleurant  (Fig.  205).  The  position  of  the 
patient  and  of  the  operator  is  the  same  as  that  just  de- 
scribed. The  index-finger  of  the  left  hand  marks  the 
point  accurately  in  the  middle  line  just  above  the  symphy- 
sis, where  the  puncture  is  to  be  made.     The  instrument 


Fig.  205. — Trocar  for  puncture  of  the  bladder,  after  Fleurant. 

is  applied  vertically  and  pushed  forcibly  through  the  ab- 
dominal wall.  When  the  disappearance  of  resistance 
indicates  that  the  abdominal  wall  has  been  passed  the 
instrument  is  pushed  onward  and  its  handle  is  raised  so 
that  its  extremity  is  directed  toward  the  fundus  of  the 
bladder.  The  stilet  is  now  removed  (Fig.  207)  and  a 
suitable  tube  passed  through  the  cannula.  The  cannula 
remains  in  place  for  about  a  week,  after  which  a  Nelaton 
catheter  is  introduced  into  the  fistula  and  fixed  in  the 
wound. 

External  Urethrotomy. — External  urethrotomy  consists 
in  entering  the  urethra  through  an  incision  in  the  abdomi- 
nal wall.  The  operation  is  undertaken  (1)  in  the  presence 
of  calculi  and  foreign  bodies  in  the  urethra,  whose  removal 

22 


338 


OPERATIVE  SURGERY. 


cannot  be  effected  through  the  natuml  passages  ;  (2)  in  the 
presence  of  injuries  of  the  urethra  ;  (3j  in  the  presence  of 
strictures  of  the  urethra  which  are  either  impermeable  or 
not  accessible  to  treatment  by  dilatation  for  various  rea- 
sons ;  (4)  for  the  establishment  of  a  urethral  fistula  ;  (5) 
as  a  preliminary  operation  to  median  section  for  stone. 


Fig.  206.— Puncture  of  the  bladder:  position  for  making  the  puncture. 

The  mucous  membrane  of  the  urethra  is  readily  reached 
with  the  knife  in  its  pendulous  portion  after  division  of 
the  skin,  the  dense  fascia,  and  the  corpus  spongiosum. 
The  bulb  of  the  urethra  is  accessil)le  in  the  middle  line 
through  an  incision  in  the  perineal  raphe,  after  division 
of  the  skin,  the  tunica  dartos,  the  superficial  perineal 
fascia,    and    the   bulbocavernosus    muscle.       The   corpus 


OPERA TIOXS   UFOX  GEyiTO-URINARY  ORGAXS.     339 

spongiosoum  is  thicker  in  this  situation  than  elsewhere, 
so  that  the  urethra  lies  at  greater  depth  than  common. 
To  the  central  side  of  the  bulb  the  urethra  recedes  more 
and  more  from  the  superHcial  level  of  the  perineum,  pass- 
ing in  an  arch  upward  and  backward  to  the  orifice  of  the 
bladder.     The  rectum  lies  with  its  anterior  wall  in  close 


Fig.  207.— Piiucture  of  the  bladder:  removal  of  the  trocar. 

relation  to  the  prostate  gland  and  is  indirectly  attached  to 
the  bulb  of  the  urethra  at  its  perineal  curve  through  some 
fibers  of  the  sphincter  ani  and  bulbocavernosus  mus- 
cles. If  it  i.s  desired  to  reach  the  membranous  or  the 
prostatic  portion,  the  muscular  and  fibrous  connections 
between  the  anus  and  the  prostate  gland  must  be  divided 
transversely,  when  after  blunt  dissection  of  the  rectum, 


340  OPERATIVE  SURGERY. 

which  is  reflected  toward  the  sacrum,  the  proximal  por- 
tions of  the  urethra,  the  membranous  portion  and  the 
prostate  are  rendered  visible  and  accessible  to  surgical 
intervention. 

The  performance  of  urethrotomy  is  subject  to'various 
modifications  in  accordance  with  the  indications  for  the 
operation.  The  patient  lies  upon  his  back  with  the  lower 
extremities  flexed  at  the  knee  and  the  hip  (position  for 
cutting  for  stone).  The  operator  is  seated  in  front  of  the 
patient.  The  urethra  is  invariably  opened  in  the  median 
line  through  the  raphe  of  the  perineum. 

Urethrotomy  icith  a  Guide. — A  metallic  sound  grooved 
upon  its  convexity  is  introduced  into  the  urethra  to  a  point 
beyond  the  constriction  that  is  to  be  divided.  The  guide 
is  held  by  an  assistant  accurately  in  the  middle  line.  If 
the  incision  is  to  be  made  into  the  perineum,  the  scrotum 
is  lifted  up.  The  operator  determines  by  touch  with  the 
finger  the  position  of  the  resistant  portion  of  the  urethra, 
which  is  perhaps  a  stricture  surrounded  by  callus,  and 
makes  an  incision  over  it  in  the  middle  line.  If  the  nar- 
rowing be  at  the  junction  between  the  bulbous  and  mem- 
branous portions,  the  incision  passes  from  the  root  of  the 
scrotum  almost  to  the  anus.  By  dissecting  layer  by  layer 
in  the  median  line  the  callous  and  narrowed  portion  of  the 
urethra  is  reached  and  an  incision  is  made  in  the  line  of 
the  cutaneous  wound  until  the  groove  in  the  guide  is  ex- 
posed. The  callus  is  divided  up  to  a  point  where  the 
urethra  is  of  normal  caliber.  The  introduction  of  a  re- 
tention-catheter concludes  the  operation. 

Urethrotomy  icithout  a  guide  is  an  incomparably  more 
difficult  operation  than  that  just  described.  The  operator 
occupies  the  same  position  as  in  cutting  for  stone.  The 
sound  can  be  introduced  only  to  the  anterior  portion  of  the 
stricture  if  this  be  impermeable.  The  cutaneous  incision 
is  made  as  in  the  operation  just  described,  in  the  median 
line  through  the  perineal  raphe.  The  portion  of  the 
urethra  lying  to  the  distal  side  of  the  constriction  is 
incised  and  the  margins  of  the  wound  are  separated  by 


OPERATIONS   UPON  GENITO-URINARY  ORGANS.     341 

means  of  small  tonaciila.  An  effort  is  made  to  find  tiie 
lumen  of  the  constriction  and  to  gain  entrance  by  means 
of  a  thin  bulbous  instrument.  If  this  can  be  done,  the 
cicatricial  tissue  is  dividcjd  in  the  middle  line  on  its  under 
surface  to  the  sound,  and  the  incision  is  continued  beyond 
the  narrowing  of  the  urethra. 

As  a  rule,  the  detectipn  of  the  canal  of  the  urethra  at 
the  distal  extremity  of  the  stricture  is  attended  with  diffi- 
culty. The  tissues  are  changed  from  the  presence  of 
cicatrices,  and  the  hemorrhage  from  the  cavernous  bodies 
and  from  the  bulb  is  often  considerable,  so  that  it  can  be 
readily  understood  that  the  small  lumen  of  the  urethra 
may  escape  detection  in  the  limited  field  of  operation. 
Indiscriminate  incision  into  the  callus  is  not  to  be  com- 
mended. By  means  of  manual  expression  of  the  bladder 
it  may  be  possible  under  circumstances  to  cause  the  escape 
of  a  few  drops  of  urine  into  the  wound  and  in  this  way  to 
gain  an  idea  as  to  the  situation  of  the  orifice  of  the  strict- 
ure. If  it  has  been  possible  by  this  means,  under  guid- 
ance of  the  eye,  to  introduce  a  bulbous  bougie  into  the 
orifice  of  the  stricture,  the  division  of  the  narrowed  por- 
tion of  the  urethra  will  be  unattended  with  any  further 
difficulty. 

After  division  of  the  stricture  a  catheter  of  consider- 
able caliber  can  always  be  introduced  with  aid  from  the 
Avound  through  the  entire  urethra  into  the  bladder.  In 
the  event  of  failure  to  divide  the  stricture  through  the 
wound  there  remains  yet  the  resource  of  retrograde  sound- 
ing of  the  stricture,  j^ostenor  catheterization.  This  may 
be  undertaken  : 

(1)  Through  the  urethra,  after  exposure  and  incision  of 
the  urethm  to  the  proximal  side  of  the  stricture ; 

(2)  Through  the  bladder,  after  this  has  been  opened  by 
means  of  a  suprapubic  incision. 

In  performing  retrograde  catheterization  through  the 
urethra  the  deeper  portions  of  this  canal  (the  membranous 
portion)  are  exposed  by  detaching  the  lowermost  ex- 
tremity of  the  rectum.     To  this  end  the  perineal  longi- 


342  OPERATIVE  SURGERY. 

tudinal  incision  is  either  prolonged  to  the  anus  or  the 
detachment  of  the  rectum  is  undertaken  through  a  pre- 
rectal  curved  incision.  After  division  of  the  skin  the 
connections  between  the  sphincter  ani  and  the  bulbocaver- 
nosus  muscles  are  divided  transversely  and  then  the 
anterior  wall  of  the  rectum  is  freed  by  blunt  dissection 
from  the  cutaneous  covering.  If  the  bulb  of  the  urethra 
is  retracted  upward  and  the  rectum  downward,  the  mem- 
branous portion  can  be  dissected  in  the  upper  angle  of  the 
wound.  The  meml^ranous  portion,  which  is  readily 
palpable  as  a  rounded  prominence,  is  incised  longitudi- 
nally for  a  distance  of  about  1  cm.,  and  retrograde  sound- 
ing can  be  practised  through  the  narrovred  portion,  which 
is  then  divided. 

Retrograde  sounding  of  the  stricture  can  be  practised 
also  from  the  bladder,  after  this  has  been  opened  through 
a  suprapubic  incision.  The  patient  lies  upon  his  back, 
with  the  pelvis  elevated,  and  the  bladder  is  opened  in  the 
usual  manner  above  the  symphysis  pubis.  The  incision 
in  the  bladder  is  held  open  by  tenacula  and  an  English 
catheter  of  small  caliber  is  pushed  forward  under  the 
guidance  of  a  finger  through  the  neck  of  the  bladder  into 
the  urethra  to  the  point  of  obstruction.  The  patient  may 
be  placed  in  the  position  as  for  the  operation  for  stone,  the 
wound  in  the  perineum  held  open  by  tenacula  and  the 
stricture  is  passed  or  merely  entered  by  pushing  the 
catheter  forward  from  the  bladder.  In  the  first  event 
the  stricture  is  divided  down  to  the  catheter;  in  the 
second,  the  portion  of  the  urethra  lying  to  the  proximal 
side  of  the  stricture  is  opened  and  the  stricture  itself  is 
successively  divided  with  scissors  from  behind  forward. 
The  last  step  is,  as  a  rule,  effected  without  difficulty. 

Urethrotomy  is  indicated  after  traumatic  rupture  of  the 
urethra,  complete  or  incomplete,  when  catheterization  is 
attended  with  difficulty,  or  urinary  infiltration  is  threat- 
ened. The  incision  is  made  through  the  perineum  in  the 
raphe,  over  the  greatest  prominence  of  the  perineal  bulg- 
ing that  is  always  present.     After  division  of  the  skin 


OPERATIOSS   VPOX  GEyiTO-VRiyARY  ORGAyS.     343 

and  the  snporfic-ial  fa.-cia,  ontniiico  i-  gtiinod  to  thewoiind- 
t-avitv  tillc<l  with  l>l<KKl-cl<»ts.  Tlic  wound  is  can  fully 
exj)l()R'd  in  all  its  parts;  the  pcrrphcral  i?tunip  is  always 
readily  found,  while  the  central  extremity  of  the  urethra 
is  frecjuently  retracted,  though  often  enough  visible,  free 
in  the  wound. 

Primary  suture  i.s  only  rarely  practised  on  account  of 
the  contused  state  of  the  extremities  of  the  urethra..  A 
soft  catheter  is  introduced  through  the  orifice  of  the 
urethra  into  the  wound  and  passed  through  the  central 
stump  into  the  bladder,  and  fixed  in  place,  the  wound- 
cavity  being  tamponed. 

The  .-implest  f<»rm  of  urethrotomy  is  practised  in  cases 
in  which  a  stone  or  foreign  body  in  the  urethra  is  to  be 
removed  throuirh  an  incision  from  without.  The  incision 
is  made  upon  the  under  surface  of  the  urethra,  directly 
upon  the  palpable  foreign  body.  The  mucous  meml^rane 
is  opened  by  a  linear  incision,  the  stone  extracted,  and 
the  wound  in  the  urethra  closed  by  suture.  The  fascia 
and  the  skin  are  united  at  a  second  sitting.  A  retention- 
catheter  is  introduced. 

Internal  Uretlirotomy. — Internal  urethrotomy,  division 
of  a  stricture  from  the  lumen  of  the  urethra,  is  indicated 
in  the  presence  of: 

(1)  A  contracting  stricture. 

(2)  Xarrowing,  with  consecutive  disease  of  the  urinar^' 
passages,  if  dilatation  is  always  attended  with  fever, 
exacerbations  of  an  existing  cystitis,  etc. 

(3)  Complete  retention  of  urine  in  consequence  of 
stricture,  especially  in  all  cases  in  which  rapid  restoration 
of  a  large  caliljer  for  the  urethra  is  desired. 

3TofJe  of  Pcrfonning  Internal  Urethrotomy : 
0)  Introduction  of  a  filiform  bougie,  to  whose  extremity 
is  attached  the  rigid  sound  provided  with  a  groove  for  the 
knife. 

(2)  The  cannulated  sound  is  passed  through  the  strict- 
ure accordinir  to  the  rules  for  catheterization  with  rigid 
instruments. 


344  OPERATIVE  SVUGERY. 

(3)  The  blade  r»f  the  urethrotome  is  introduced  into  the 
canal  of  the  guiding  sound  and  pushed  for^^■ard  to  the 
stricture ;  by  pressure  upon  the  end  of  the  blade  the 
stricture  is  divided  through  the  upper  wall  of  the 
urethra. 

(4)  After  reuKAal  of  the  entire  instrument,  a  retention- 
catheter  (caliljer  16)  is  introduced  into  the  urethra. 

Lateral  Incision  for  Stone. — The  patient  is  placed  in  the 
usual  position  for  stone-oj^erations,  with  the  operator  sit- 
ting in  front.  A  convex  grooved  sound  is  introduced 
into  the  urethra  and  held  vertically  by  an  assistant,  with 
the  groove  directed  toward  the  left.  The  incision  passes 
from  the  middle  of  the  perineal  raphe  to  a  point  midway 
between  the  anus  and  the  left  ischial  tuberosity.  Deep 
dissection  is  proceeded  with,  the  position  of  the  groove  in 
the  guide  being  constantly  kept  in  mind.  After  the 
deeper  layers  of  the  perineum  (su2:)erficial  and  deep  peri- 
neal fascia,  superficial  transverse  perineal  muscle)  have 
been  passed  and  the  urethra  has  l3een  opened  upon  one^ 
side  (avoiding  the  bulbj  the  groove  of  the  instrument  will 
come  into  view  in  the  wound.  The  operator  grasps  the 
guide  with  his  left  hand  and  introduces  into  the  wound  a 
blunt-pointed  knife,  with  its  edge  directed  downward,  in 
such  a  manner  that  it  lies  with  its  back  directly  against 
the  guide.  AVhile  the  handle  of  the  guide  is  depressed, 
the  operator  divides  the  membranous  portion  up  to  the 
prostatic  portion  Avith  the  blunt-pointed  knife  (lithotome), 
which  he  pushes  forward  in  the  direction  of  the  urethra. 
At  this  moment  the  contents  of  the  Vjladder  stream  into 
the  wound  by  the  side  of  the  guide.  The  wound-canal 
is  enlartred  instrumentallv  or  with  the  fino^er,  which  is 
permitted  to  enter  the  bladder,  and  the  calculus  is  ex- 
tracted with  stone-forceps  or  a  stone-spoon.  In  the  after- 
treatment  a  catheter  is  permitted  to  remain  in  the  urethra 
and  the  wound  is  tamprmed. 

Median  Section  for  Stone. — The  details  for  the  operation 
are  precisely  like  those  just  described.  The  guide  is  held 
accurately  in  the  median   line,  with  its  groove  directed 


OPERATIONS   UPON  GENITO-V BINARY  ORGANS.     345 

forward.  Tlu'  cutaneoiLs  incision  passes  thronuli  the  peri- 
neal raphe,  beginning- just  behind  tlie  attachment  ol*  the 
scrotnni  and  extending  for  a  distance  of  5  or  6  cm.  to- 
ward the  anus.  The  knife  is  introcbiced  deeply  in  a  ver- 
tical direction,  an  endeavor  being  made  to  reach  the 
membranous  portion  of  the  urethra,  with  avoidance  of  the 
bulb.  The  urethra  is  opened  in  the  median  line  and  the 
incision  is  pr(>longed,  as  in  the  operation  just  described,  by 
means  of  the  blunt-pointed  knife  to  the  prostatic  portion. 
The  stone  is  now  removed  in  the  typical  manner. 

The  lateral  and  median  incisions  for  stone,  which  in  the  past  were  the 
customary  operations,  possess  to-day  but  a  limited  field  of  application, 
having  been  almost  completely  displaced  by  the  suprapubic  incision.  [Dis- 
placed particularly  by  litholapaxy. — Ed.]  The  median  incision,  the  more 
recent  of  the  two,  was  chosen  in  order  to  avoid  the  division  of  the  ejacu- 
latory  ducts  that  has  heen  observed  repeatedly  as  a  result  of  the  lateral 
incision.  Both  methods  are  attended  with  the  disadvantage  that  the 
removal  of  large  stones  through  the  narrow  wound-canal  can  be  effected 
only  with  difficulty,  so  that  the  wound  itself  is  distorted  and  lacerated 
in  the  efforts  at  extraction  and  dilatation  and  the  conditions  for  recovery 
are  rendered  less  favorable  than  otherwise  they  would  be.  Finally,  a 
typical  form  of  true  incontinence,  permanent  dribbling  of  urine,  is  not 
rarely  observed  after  the  median  or  the  lateral  incision,  even  when 
union  has  proceeded  smoothly. 

Urethrostomy. — In  cases  of  incurable  stricture  Poncet 
excludes  entirely  the  narrowed  portion  of  the  urethra  by 
means  of  perineal  urethrostomy,  dividing  the  urethra  on 
the  proximal  side  of  the  stricture  and  permitting  it  to 
open  upon  the  perineum.  The  stricture  is  exposed  by 
means  of  the  usual  incision  through  the  perineal  raphe, 
when  the  urethra  is  divided  transversely  on  the  proximal 
side  of  the  stricture,  and  is  sutured  in  the  lower  angle  of 
the  cutaneous  wound.  Poncet  divides  the  central  stump 
throughout  a  slight  extent  on  its  under  side  before  suturing 
it  in  the  wound.  The  peripheral  stump  of  the  urethra  is 
sutured  and  dropped  into  the  wound,  when  the  cutaneous 
wound  is  closed  by  suture  up  to  the  opening  of  the  fistula. 

Litholapaxy. — Instrumental  endovesical  crushing  of 
stone  in  the  bladder,  followed  immediately  by  evacua- 
tion of  the  fragments,  is  designated  litholapaxy.  The 
instrument   for  destroying   the   stone  is  made  of  steel, 


346  OPERATIVE  SURGERT. 

shaped  like  a  catheter,  and  consists  of  two  blades  fitting 
one  into  the  other  and  the  tip  of  one  of  which  is  serrated. 
The  instrument  grasps  the  stone  between  its  two  blades, 
which  can  be  secured  firmly  and  are  brought  together  by 
means  of  a  screw-mechanism ;  the  stone,  thus  grasped,  is 
crushed  between  them=  To  attain  good  results  with  the 
operation  of  litholapaxy  a  careful  selection  of  cases,  as 
well  as  skill  in  the  use  of  the  instrument,  is  required. 

Mode  of  Procedure. — The  patient  occupies  the  dorsal 
decubitus,  with  the  pelvis  somewhat  elevated.  The  blad- 
der is  filled  moderately  with  sterile  solution  of  boric  acid. 
The  lithotrite  is  introduced  according  to  the  rules  laid 
down  for  catheterization,  the  operator  standing  upon  the 
right  side  of  the  patient.  An  attempt  is  made  to  touch 
the  stone  with  the  tip  of  the  closed  instrument,  when  the 
blades  are  separated  to  grasp  the  stone.  The  blades  of 
the  instrument  are  fixed  by  means  of  a  sliding  arrange- 
ment on  its  handle,  and  the  stone  is  crushed  by  means 
of  the  screw-meclianism.  Xow,  the  individual  fragments 
of  the  broken  calculus  are  grasped  separately  and  are 
crushed.  Finally,  the  residue  is  converted  into  a  fine 
powder  by  crushing.  A  rigid  catheter  is  introduced  and 
the  bladder  is  irrigated,  with  the  escape  of  sand.  With 
the  bladder  moderately  full  the  evacuation-catheter  is 
connected  ^\  ith  a  pump,  whose  activity  is  continued  as 
long  as  fragments  of  stone  are  present  in  the  bladder.  If 
a  rather  large  fragment  of  stone  can  be  felt,  this  must  be 
reduced  further  in  size  by  means  of  the  lithotrite.  The 
cystoscope  permits  confirmation  by  ocular  inspection  of 
the  fact  that  complete  evacuation  of  the  fragments  has 
been  effected.  AVith  a  proper  selection  of  the  cases  the 
results  of  litholapaxy  may  be  admirable. 

Operations  on  the  Bladder. — The  bladder,  situated 
in  the  true  pelvis  just  behind  its  anterior  wall,  is  attached 
to  the  pubic  arch  through  the  prostate  gland  and  the 
pubovesical  ligament.  Beside,  the  organ  is  held  in  place 
within  certain  limits  by  the  visceral  layer  of  the  pelvic 
fascia,  by  the  vesico-umbilical  ligaments  and  by  the  peri- 


OPERATIONS  ON  THE  BLADDER.  347 

toiu'um.  The  jxritonoum  pasH^es  from  the  anterior  al)- 
dominal  wall  and  troni  the  lateral  walls  of  the  pelvis  upon 
the  bladder,  whose  fundus  and  posterior  and  lateral  walls 
it  covers.  AMien  eni])ty,  the  bladder  is  concealed  behind 
the  symphysis.  A\  hen  Idled,  the  up])er  portion  rises  above 
the  pelvic  brim,  so  that  the  anterior  wall  of  the  bladder 
not  covered  by  ])eritoneum  comes  to  lie  in  immediate 
juxtaposition  with  the  abdominal  wall.  The  bladder  can 
thus  be  opened  above  the  symphysis  without  injury  to  the 
peritoneum  if  filled  to  the  maximum. 

Suprapubic  Cystotomy. — Opening  of  the  bladder  above 
the  symphysis  pubis. 

The  operation  is  indicated  : 

(1)  In  the  presence  of  calculi  and  other  foreign  bodies 
in  the  bladder ; 

(2)  In  the  presence  of  tumors  of  the  bladder ; 

(3)  In  the  presence  of  tuberculosis  of  the  bladder  ; 

(4)  In  cases  of  vesical  hematuria  ; 

(5)  In  cases  of  rupture  of  the  bladder ; 

(6)  For  the  removal  of  hypertrophied  lobes  of  the 
prostate  gland ; 

(7)  For  the  purpose  of  forming  a  fistula  ; 

(8)  In  cases  of  severe  cystitis  ; 

(9)  As  a  preliminary  operation  in  the  performance  of 
posterior  catheterization. 

The  mode  of  procedure  is  subject  to  various  modifica- 
tions in  accordance  with  the  indications  for  its  perform- 
ance.    Three  types  of  operation  are  distinguished  : 

(1)  Simple  opening  of  the  bladder  for  the  removal  of 
calculi  and  other  foreign  bodies  ; 

(2j  Opening  of  the  bladder  for  the  purpose  of  inider- 
taking  endovesical  manipulations  (extiq)ation  of  tumors, 
etc.)  ; 

(3)  Opening  of  the  bladder  for  the  purpose  of  estab- 
lisliing  a  fistula. 

In  all  cases  the  bladder  is  distended  to  the  maximum 
by  the  injection  of  fluid  into  its  cavity,  so  that  it  rises 
above  the  level  of  the  symphysis.     If  it   is  impossible 


348 


OPERATIVE  SURGERY. 


thus  to  fill  the  bladder,  the  anteriDr  wall  of  the  visciis  is 
forced  into  the  wound  by  means  of  a  concave  grooved 
guide  and  incised. 

1.  Suprapubic  Cystoiomy  for  Stone.-— T\\e  patient  occu- 
pies the  dorsal  decubitus,  with  the  pelvis  somewhat  raised 
bv  means  of  a  pillow,  and  the  operator  stands  to  his 
right  side.  After  the  abdominal  wall  has  been  cleansed 
and  shaved,  a  catheter  is  introduced  and  the  bladder  is 
irrigated   until  the  escaping  fluid  is  clear.     Sterile  fluid 


Fig.  208. — Suprapubic  cystotomy :  the  anterior  wall  of  the  blarlder 
is  exposed;  near  its  summit  is  the  i)oint  of  reflection  of  tte  peritoneum. 

is  now  permitted  to  flow  into  the  bladder  through  an 
irrigator  or  a  sufficient  quantity  is  injected  to  cause  the 
bladder  to  become  palpable  as  a  tense  swelling  above  the 
symphysis  pubis.  The  catheter  is  removed  and  the 
penis  is  surrounded  with  a  strip  of  gauze.  The  incision 
is  made  in  the  linea  alba  just  al)Ove  the  symphysis,  and  is 
from  5  to  7  cm.  long.  Passing  directly  to  the  depth  of 
the  wound  the  fatty  layer  is  traversed  and  the  anterior 
rectus  sheath  or  the  fibrous  linea  alba  is  divided.  The 
rectus  muscles  are  retracted,  and  in  the  space  of  Retzius 


OPERATIoyS  Oy  THE  BLADDKH.  349 

thus  exposed  tlie  l)la(l(U'r  is  palpable  as  a  tense  mass. 
The  prevesical  fat  is  displaced  Iruni  the  bladder  In- 
blunt  dissection  by  means  of  two  pairs  of  forceps,  until 
the  anterior  wall  of  the  viscus,  recognizable  bv  the  differ- 
ence in  color  and  by  the  bundles  of  muscles  and  veins 
ujxm  its  surl'ace,  is  ex{x»sed  (Fig.  208). 

Just  below  the  transverse  line  of  reflection  of  the 
jK'ritoneum  a  simple  pointed  tenaculum  is  introduced  into 
the  wall  of  the  bladder,  which  is  divided  in  the  median 
line  with  a  slmrp-pointed  knife,  in  the  direction  of  the 
symphysis.  The  margins  of  the  wound  are  held  apart  by 
means  of  two  retractors.  The  ojx-rator  introduces  the 
index-hnger  of  his  left  hand  into  the  bladder,  touches  the 
stone  or  the  foreign  body,  and  permits  the  stone-forceps 
to  follow  the  palmar  aspect  of  the  finger  to  the  calcidus. 
The  blades  of  the  forceps  are  now  separated,  the  stone 
grasped  and  removed  from  the  wound.  The  wound  in 
the  wall  of  the  bladder  can  be  closed  at  once  by  suture. 
Various  complicated  methods  of  suture  of  the  bladder 
have  been  abandoned.  The  wotmd  in  the  viscus  is  closed 
by  a  series  of  interrupted  catgut-sutures,  including  the 
entire  thickness  of  the  wall  of  the  bladder,  with  the  ex- 
ception of  the  mucous  membrane. 

Fixation  of  the  sutured  bladder  to  the  abdominal  wall 
(ri/.^topexy)  is  not  without  advantage.  Suture  of  the 
wall  of  the  bladder  may  be  omitted  and  the  wound  in  the 
viscus  be  permitted  to  remain  open.  The  urine  is  re- 
moved by  suction  and  the  bladder  is  by  this  means  kept 
perfectly  at  rest. 

2.  Suprapubic  Cystotomy  for  the  Purpose  of  Zliderfak- 
ing  Intravesical  Manipulations. — If  opening  of  the  bladder 
is  effected  as  a  preliminary  procedure  to  facilitate  intra- 
vesical manipulations,  it  is  best  to  raise  the  pelvis  as  high 
as  possible.  The  preparations  for  the  operation,  and  the 
opening  of  the  bladder,  are  made  in  the  manner  already 
described.  After  the  bladder  has  been  opened  a  view  of 
its  interior  should  be  possil)le.  To  this  end  the  margins 
of  the  wound  in  the  bladder  are  held  apart  by  means  of 


350  OPERATIVE  SURGERY. 

Plate  21.— Suprapubic  Cystotomy  with  the  Pelvis  Elevated. 

The  wouud  is  enlarged  by  the  introduction  of  retractors  and  the  in- 
terior of  the  bladder  is  rendered  visible.  The  wall  of  the  viscus  has 
been  provisionally  attached  to  the  skin  by  suture.  There  may  be  observed 
the  mouth  of  the  urethra,  the  trigone,  and  the  entrances  of  the  ureters. 
The  wall  of  the  summit  of  the  bladder  appears  as  a  prominence  above 
the  broad  speculum. 

retractors  resembling  vaginal  specula,  while  a  broad  Simon 
speculum  is  introduced  in  the  upper  angle  of  the  Avound. 
If,  beside,  the  interior  of  the  viscus  is  illuminated  by 
means  of  an  incandescent  lamp,  inspection  is  readily  pos- 
sible and  the  operator  may  undertake  a  variety  of  manipu- 
lations within  the  cavity  of  the  bladder  (excision  of 
tumors,  control  of  hemorrhage,  suture  of  deficiencies  in 
the  mucous  membrane,  excochleations,  etc.)  (Plate  21). 

if  after  extirpation  of  vesical  tumors  bleeding  has  been 
completelv  controlled,  the  bladder  may  be  closed  by  suture. 
After  excochleation  of  malignant  tumors,  and  after  opera- 
tions upon  the  prostate,  drainage  of  the  bladder  is  the  pre- 
feraVjle  m(.>de  of  procedure. 

Bv  making  a  transverse  incision  through  the  skin  and 
opening  the  bladder  in  the  same  manner,  after  division  of 
the  recti  muscles,  general  access  to  the  interior  of  the 
viscus  is  possible. 

Suggestions  have  been  made  by  a  number  of  operators 
to  expose  the  bladder  throughout  a  greater  extent  by 
means  of  operations  upon  the  bony  parts.  To  this  end 
Helferich  resects  a  triangular  portion  of  the  symphysis 
pubis,  while  Bramann  recommended  temporary  partial 
resection  of  the  symphysis,  and  Xiehans  lateral  resection 
of  the  pelvis. 

3.  Section  of  the  Bladder  for  the  Purpose  of  Establish  ing  a 
Fisfida. —  Crfsfostomi/. — In  the  performance  of  cystostomy 
a  short  longitudinal  incision  is  made  above  the  symphysis 
pubis  according  to  the  method  of  Poncet,  and  the  bladder 
is  opened  in  the  usual  manner.  The  Avail  of  the  bladder 
is  brouo:ht  to  the  level  of  the  skin  and  fixed  in  place  by 


Tab.  21 


r^ 


X 


St  F  Reichhold.  Mund 


OPERATIONS   UPOy  THE  PROSTATE  GLAND,  ETC,  351 


OPEEATIO^'S   UPON  THE  PROSTATE  GLAND,  ETC.      353 


"^   c3 


23 


OPERATIOXS   UPON  THE  PROSTATE  GLAND,  ETC.   355 

sutures.  The  cutaneous  wound  is  closed  in  its  upper  por- 
tion, while  the  vesical  nuicous  membrane  is  sutured  in  its 
lower  portion.  The  establishment  of  a  fistula  may  be 
effected  also  without  suture  of  the  vesical  mucous  mem- 
brane, bv  the  employment  of  simple  siphon-drainage. 
The  curved  tube  may  in  the  further  course  of  the  case  be 
replaced  by  a  soft  catheter,  which  is  introduced  into  the 
bladder  throiio'li  the  wound  and  is  permitted  to  remain. 

Operations  upon  the  Prostate  Gland,  the  Semi- 
nal Vesicles,  and  the  Vas  Deferens. — Prostatotomy. 
— Opening  of  the  prostate  through  an  incision  in  the  peri- 
neum is  ijidicated  in  the  presence  of  abscesses  and  for  the 
excochleation  of  tuberculous  masses  in  the  gland.  After 
the  root  of  the  penis  and  the  superficial  transverse  perineal 
muscle  are  exposed  by  an  incision  through  the  perineum 
and  the  connections  between  the  sphincter  ani  and  bulbo- 
cavernosus  muscles  are  divided  transversely,  the  anterior 
wall  of  the  rectum  can  be  separated  by  blunt  dissection 
from  the  prostate  gland  and  reflected  toward  the  sacrum. 
Between  the  triangular  ligament  of  the  urethra  and  the 
rectum  thus  displaced  the  slightly  convex  posterior  aspect 
of  the  prostate  lies  exposed  throughout  its  entire  extent 
(Fig.  210).  Connected  with  the  base  of  the  prostate  are 
the  seminal  vesicles,  and  by  continued  detachment  of  the 
rectum  from  the  bladder  the  fundus  of  the  latter  will  be 
exposed,  when  the  seminal  vesicles  and  the  vasa  deferentia 
will  be  visible  in  the  wound. 

The  performance  of  prostatotomy  in  the  presence  of  an 
abscess  is  performed  as  follows  :  the  patient  occupies  the 
same  position  as  in  the  operation  for  stone,  and  an  English 
catheter  of  large  caliber  is  introduced  into  the  urethra. 
The  operator  sits  in  front  of  the  patient  and  guides  the 
knife  with  his  right  hand,  while  the  index-finger  of  the 
left  hand  is  introduced  into  the  rectum,  in  order  that  in 
the  progress  of  the  deep  dissection  the  anterior  wall  of 
the  rectum  shall  be  avoided  (Fig.  209).  A  curved  in- 
cision 4  or  5  cm.  long  is  made  through  the  prerectal 
tissues.     After  division  of  the  skin  and  the  subcutaneous 


356  OPERATIVE  SURGERY. 

connective  tissue  the  perineal  septum  is  divided  trans- 
versely and  blunt  dissection  is  made  between  the  rectum 
and  the  urethra  upward  toward  the  prostate.  When  the 
lower  pole  of  this  organ  or  a  portion  of  its  posterior  wall 
is  exposed  in  the  wound,  a  grooved  director  or  a  pair  of 
forceps  with  closed  l)lades  is  introduced  into  tlie  fluctuat- 
ing portion,  when  the  pus  escapes  through  the  wound. 
The  opening  is  now  suitably  enlarged  and  the  abscess- 
cavity  is  tamponed.  If  a  communication  exists  between 
the  abscess-cavity  and  the  urethra,  the  retention  of  a 
catheter  is  necessary  in  the  after-treatment. 

Extirpation  of  the  Seminal  Vesicles. — In  extirpation  of 
the  seminal  vesicles  the  perineal  route  just  described 
appears  the  most  desirable.  The  patient  and  the  operator 
occupy  the  same  positions  as  in  the  operation  just  con- 
sidered. A  large  perineal  flap-incision  is  made  Avhose 
posterior  extremity  on  either  side  extends  to  the  tuber- 
osities of  the  ischium  and  whose  anterior  l^oundary  lies  in 
front  of  the  rectum.  The  mode  of  procedure  in  the 
depth  of  the  w^ound  is  analogous  to  that  pursued  in  the 
performance  of  prostatotomv.  The  detachment  of  the 
rectum  is  undertaken  through  a  considerable  extent  until 
the  seminal  vesicles  and  the  fundus  of  the  bladder  become 
visible  on  displacement  of  the  rectum  toward  the  sacrum. 
The  altered  seminal  vesicles  are  j^eeled  out  of  their  sur- 
roundings, dissected  from  the  fundus  of  the  bladder,  and 
removed.  At  the  same  time  morbid  collections  in  the 
prostate  gland  can  be  excised. 

Excisions  of  the  Prostate ;  Prostatectomy. — In  cases 
of  hypertrophy  of  the  prostate  gland  removal  of  the 
enlarged  middle  and  lateral  lol^es  has  l^een  recommended 
for  the  relief  of  the  difficulty  in  urhiation  and  has  been 
practised  by  numerous  surgeons  with  varying  success.  The 
question  whether  cure  is  effected  by  removal  of  the  pros- 
tatic obstruction  is  not  as  yet  decided.  At  any  rate,  ad- 
vanced cases  in  which  secondary  changes  in  the  wall  of 
the  bladder  and  of  the  upper  urinary  passages  have  taken 
place  are  not  adapted  to  the  operation. 


OPERATIONS   UPON  THE  PROSTATE  GLAND,  ETC.  357 

The  enlarged  middle  lobe  of  the  prostate,  which  often 
attains  the  size  of  a  walnnt  and  more,  may  ho  extirpated 
tln-oiigh  the  suprapubic  incision  into  tiie  ljhi(hler  Q>{.  C. 
Gill).  The  hhidder  is  opened  above  the  symphysis  pubis 
in  the  Usual  maimer  and  the  prominent  tumor  is  removed 
with  the  Paquelin  cautery,  or  the  galvanoeaustic  loop,  or 
with  curved  scissors.  .  The  base  of  the  wound  is  cauter- 
ized for  the  control  of  hemorrhage,  and,  if  necessary,  the 
bladder  is  tamponed. 

The  enlarged  lateral  lobes  of  the  prostate  can  be  only 
partially  removed  or  excised,  care  being  taken  to  avoid 
opening  the  urethra.  In  the  performance  of  partial  resec- 
tion adequate  exposure  of  the  body  of  the  prostate  is 
essential.  The  glanxl  is  exposed  either  with  the  aid  of  the 
perineal  prerectal  incision  or  through  a  sacral  incision.  The 
details  of  the  first  method  are  given  on  page  35e5.  The 
sacral  method  of  exposing  the  prostate  has  been  recom- 
mended l)y  Dittel  (lateral  prostatectoiny).  In  this  mode 
of  procedure  an  incision  is  made  in  the  folds  of  the  anus, 
the  rectum  is  displaced  laterally  and  in  this  way  the  pos- 
terior surface  of  the  ])rostate  is  brought  into  view.  The 
patient  occupies  the  right  lateral  decubitus  and  an  English 
catheter  is  introduced  into  the  urethra.  The  incision  be- 
gins at  the  apex  of  the  coccyx,  passes  in  the  middle  line 
to  the  posterior  margin  of  the  anus,  which  it  surrounds 
npon  the  right  side,  and  terminates  in  the  perineal  raphe 
in  front  of  the  amis.  The  operator  gains  entrance  into  the 
ischiorectal  fossa,  and  separates  the  rectum  by  blunt  dissec- 
tion from  the  ])rostate,  so  that  the  right  lateral  lobe  of  the 
latter  and,  if  the  dissection  be  continued,  the  entire  poste- 
rior aspect  are  exposed  to  view.  Wedge-shaped  portions  of 
the  gland  are  excised  on  either  side.  Dittel  recommends 
that  so  much  of  the  gland  be  removed  that  only  sufficient 
remains  to  surround  the  urethra.  The  removal  of  the  coc- 
cyx is  calculated  to  enlarge  the  field  of  operation. 

Resection  and  Extirpation  of  the  Vas  Deferens. — Resec- 
tion of  the  vas  deferens  in  its  contniuity  has  been  recom- 
mended recently  in  the  treatment  of  hypertrophy  of  the 


358  OPERATIVE  SURGERY. 

prostate  gland,  and  has  been  performed  in  numerous  cases. 
The  vas  deferens  is  palpable  through  the  skin  as  a  round, 
firm  strand,  and  it  may  thus  be  separated  from  the  re- 
maining structures  of  the  spermatic  cord.  The  cutaneous 
incision  for  the  isolation  of  the  vas  deferens,  3  or  4  cm. 
long,  may  be  made  either  in  front  of  the  external  inguinal 
ring,  or  at  the  neck  of  the  scrotum.  The  structures  form- 
ing the  spermatic  cord  are  forced  out  of  the  Avound,  the 
vas  deferens  is  isolated  by  touch  and  a  portion  from  2  to 
4  cm.  long  is  excised  'svith  scissors.  Removal  of  the  vas 
deferens  in  connection  with  the  testicle  becomes  necessary 
when  in  the  presence  of  tuberculosis  of  the  epididymis  the 
vas  deferens  also  is  involved  in  the  disease.  Under  these 
conditions  the  incision  for  exposure  of  the  testicle,  which 
passes  longitudinally  over  the  scrotum,  is  extended  upward 
and  outward  over  the  inguinal  canal.  Throughout  the 
range  of  the  incision  the  skin  and  the  anterior  boundary 
of  the  inguinal  canal  are  divided  so  that  the  vas  deferens 
is  exposed  in  its  course  through  this  canal,  and  is  thus 
rendered  accessible  to  surgical  removal.  The  pelvic  por- 
tion of  the  vas  deferens  would  be  accessible  by  this  means 
only  after  extended  detachment  of  the  peritoneum,  entail- 
ing injury  of  disproportionate  degree.  This  portion  of  the 
duct  is  therefore  to  be  reached  by  the  perineal  route  or 
with  the  aid  of  an  incision  such  as  I)ittel  has  reconnnended 
in  the  performance  of  lateral  prostatectomy. 

Biingner  recommended,  in  place  of  extirpation,  divuhlon 
of  the  vas  deferens.  The  duct  is  isolated  and  exposed 
throughout  a  considerable  extent  by  gradually  increased 
traction.  AVith  careful  manipulation  of  this  kind  four- 
fifths  of  tiie  entire  duct  may  be  removed. 

Extirpation  of  the  Testicle.  Castration. — The  indica- 
tions for  this  operation  consist  in  tlie  presence  of  neo- 
plasms of  the  testicle  and  tuberculosis  of  the  epididymis. 
A  new  indication  for  castration  is  afforded  by  hypertrophy 
of  tlie  prostate.  Tlie  cutaneous  incision  is  always  made 
longitudmally  over  the  greatest  convexity  of  the  tumor. 
In  making  this  incision  the  operator  grasj^s  the  scrotum 


OPERATIOXS   UPOy  THE  PROSTATE  GLAXD,  ETC  359 

with  his  left  hand  in  such  a  manner  that  the  overlying 
skin  is  made  tense.  If  the  skin  is  involved  in  the  disease- 
process  throughout  a  circumscril)ed  area  (fnjm  extension 
of  a  neoplasm,  or  the  formation  of  a  tuberculous  fistula), 
the  diseased  structure  is  included  between  the  incisions 
and  is  removed  in  conjunction  with  the  testicle.  The 
incisions  are  made  threuijch  the  skin  and  the  dartos  down 
to  the  tunica  vaginalis  and  the  testicle,  with  its  covenngs, 
is  freed  from  its  bed  by  l)luut  dissection,  so  that  it  remains 
in  connection  with  the  body  only  througli  tlie  intermedia- 
tion of  the  spermatic  cord.  By  traction  on  the  cord  its 
constituent  structures  are  more  clearly  brought  into  view. 
The  vas  deferens  is  isolated  and  ligated.  The  remaining 
structures  of  the  spermatic  cord  are  ligated  en  masse  in 
two  or  three  segments.  The  cord  is  then  divided  trans- 
versely on  the  distal  side  of  the  ligatures,  which  are  cut 
short.  The  stump  of  the  cord  retracts  into  the  depth  of 
the  wound,  and  tlie  cutaneous  wound  is  closed  by  suture. 
Operation  for  Hydrocele. — Hydrocele  is  treated  in  a 
palliative  way  by  simple  puncture  and  in  a  radical  Avay 
by  laying  open  the  tunica  vaginalis  and  excising  it.  Punct- 
ure of  a  hydrocele  is  made  in  accordance  with  the  rules 
that  govern  the  making  of  punctures  in  general.  The 
operator  must,  however,  be  assured  of  the  position  of  the 
testicle,  in  order  to  avoid  injury  of  this  organ  in  intro- 
ducing the  trocar.  The  scrotum  is  grasped  firmly  with 
the  supinated  left  hand  and  made  tense.  The  introduc- 
tion of  the  trocar  is  made  upward  through  the  anterior 
wall  close  to  the  fundus  of  the  scrotum  at  a  point  where 
no  vein  is  visible  through  the  skin.  At  first  the  fluid  is 
expelled  in  a  continuous  stream.  Later  the  escape  must 
be  facilitated  l^y  alteration  in  the  position  of  the  cannula 
and  by  kneading  movements  of  the  scrotum.  The  injec- 
tion through  the  cannula  of  from  5  to  10  gm.  of  LugoPs 
solution,  in  conjunction  with  the  puncture,  is  a  favorite 
mode  of  radical  operation  for  hydrocele.  The  procedure, 
however,  is  extremely  painful  and  with  regard  to  the  cer- 
tainty of  the  result  stands  behind  radical  incision. 


360  OPERATIVE  SURGERY. 

Radical  Incision  by  the  Method  of  Vollinann, — The 
scrotum  is  grasped  firmly  and  made  tense  with  the  left 
hand  and  an  incision  is  made  longitudinally  over  the 
greatest  convexity  of  the  tumor  almost  up  to  the  fundus. 
With  careful  dissection  the  incision  is  carried  down  to  the 
tunica  vaginalis,  which  is  divided  in  the  direction  and 
throughout  the  extent  of  the  cutaneous  incision.  After 
the  fluid  has  escaped,  the  tunica  vaginalis  is  united  to  the 
skin  by  a  row  of  sutures  and  a  strip  of  gauze  is  introduced 
into  the  cavity  that  remains.  The  process  of  healing 
often  occupies  a  considerable  period  of  time. 

Radioed  Operedion  by  the  Methoel  of  Bergnumn. — Radi- 
cal operation  by  the  method  of  Bergmann  is  followed  by 
recovery  within  a  short  time,  by  reason  of  the  fact  that 
the  wound-conditions  render  possible  union  by  primary 
intention.  A  cutaneous  incision  is  made  in  the  manner 
just  described.  Before  the  sac  of  the  hydrocele  is  opened, 
an  endeavor  is  made  to  free  it  from  the  overlying  skin 
throughout  a  considerable  extent.  After  this  has  been 
adequately  effected  the  sac  is  opened  as  in  the  operation 
of  Volkmann.  After  the  fluid  has  escaped  the  opera- 
tor grasps  the  margins  of  the  incision  through  the  tunica 
vaginalis  and  separates  this  from  the  testicle  on  either  side, 
almost  to  the  point  of  reflection.  After  this  detachment 
has  been  thoroughly  effected  the  freed  parietal  layer  of 
the  tunica  vaoinalis  is  excised.  The  maro^ins  of  the  in- 
cision  in  the  skin  are  accurately  approximated  by  suture 
over  the  testicle,  which  is  dropped  back  into  the  wound. 

Operation  for  Phimosis. — Operations  for  phimosis  in- 
clude surgical  procedures  of  various  kinds  by  means  of 
which  congenital  or  acquired  narrowing  of  the  prepuce  is 
removed.  In  performing  the  operation  either  the  prepuce 
is  divided  longitudinally  from  its  orifice  to  the  glans  [in- 
cinion)  or  the  entire  prepuce  is  removed  [circumcisioii). 
By  the  first  of  these  methods  the  incision  is  made  in  the 
middle  line  of  the  d(u*sal  surface,  a  grooved  director,  with 
its  concavity  directed  upward,  being  introduced  into  the 
orifice    between    the    prepuce   and  the  glans.     The  two 


OPERATIONS   UPON  THE  PROSTATE  GLAND,  ETC.  361 


layers  of  tlie  prepuce  are  divided  over  the  director  with  a 
single  stroke  of  the  scissors  almost  up  to  the  corona  glandis. 
After  the  division  has  been  effected  the  prepuce  must  be 
readily  retractable.  Over  the  glans  throughout  the  extent 
of  the  wound  the  mucous  membrane  of  the  ])repuce  is 
united  with  the  skin  by  means  of  a  series  of  interrupted 
sutures,  or  of  a  continuous  suture. 

Circumcision  may  be  effected  in  various  ways.     The 
prepuce  may  be  drawn  forward  as  far  as  possible  and  be 

Operation  for  Shortened  Frenum. 


Fig.  -m. 


Fig.  212. 


Fig.  211. — Transverse  division  of  the  frenum. 

Fig.  212. — Union  at  right  angles  to  the  direction  of  the  division, 

divided  just  in  front  of  the  glans,  after  which  the  margins 
of  the  outer  and  inner  layers  of  the  prepuce  are  united  by 
suture.  In  another  method  of  circumcision  the  usual 
dorsal  incision  is  first  made,  after  which  portions  of  the 
prepuce  on  either  side  of  the  incision  are  removed  with 
scissors  close  to  the  point  of  reflection  on  the  glans. 
Throuo;hout  the  entire  extent  of  the  wound  the  skin  is 
united  with  the  inner  layer  of  the  prepuce. 

Operation  for  Shortened  Frenum. — Congenital  shortness 
of  the  frenum,  with  a  normal  caliber  of  the  prepuce,  is 


362  OPERATIVE  SURGERY. 

attended  with  numerous  discomforts  (pain  in  coitus,  fre- 
quent laceration,  hemorrhage).  Simple  transverse  division 
of  the  band  is  not  to  be  recommended  on  account  of  the 
hemorrliage  that  follows.  Division  with  the  Paquelin 
cauterv  secures  immunity  from  the  hemorrhage,  but  a 
considerable  time  is  occupied  in  the  healing  of  the  wound. 
Functionally  good  results,  Avith  the  possibility  of  securing 
union  bv  primary  intention,  are  yielded  by  the  following 
minor  plastic  operation. 

The  frenum  is  divided  with  a  single  stroke  of  the  scis- 
sors to  such  a  depth  that  the  prepuce  can  be  retracted  to  a 
maximum  degree  without  tension.  The  small  wound 
thus  made  is  united  at  a  right  angle  to  the  direction  of 
the  incision  (Figs.   211  and  212). 

Amputation  of  the  Penis. — Malignant  neoplasms  con- 
stitute the  exclusive  indication  for  amputation  of  the  penis. 
This  may  be  practised  through  the  pendulous  portion  at  a 
selected  level  by  means  of  a  circular  incision.  Under 
certain  conditions  the  deeper  portions  of  the  member,  the 
roots  of  the  cavernous  bodies,  must  be  removed  by  ope- 
ration. In  all  cases,  after  ablation  of  the  parts,  the 
uretlira  must  be  suitably  situated  and  fixed  in  the  wound. 

In  amputating  the  penis  through  the  pendulous  portion 
digital  compression  is  exercised,  while  a  circular  incision 
is  made  transversely.  The  skin  is,  after  division,  re- 
tracted, when  the  operator  divides  the  cavernous  bodies 
transversely  Avith  an  amputation-knife,  cutting  from  the 
dorsal  aspect  toward  the  urethra.  When  the  urethra  is 
reached  it  is  dissected  free  for  a  short  distance  toward 
the  periphery  and  is  divided  transversely  2  cm.  in 
advance  of  the  line  of  incision  through  the  cavernous 
bodies.  The  urethra  is  snipped  through  its  inferior  sur- 
face with  a  single  stroke  of  the  scissors,  spread  upon  the 
wound  and  united  by  its  free  border  with  the  margin  of 
the  skin  by  means  of  a  series  of  sutures. 

In  amputating  the  penis  in  conjunction  with  its 
perineal  connections  the  scotum  is  divided  in  a  sagittal 
direction.     In  the  gaping  wound  the  roots  of  the  cavern- 


OPERATIONS   UPON  THE  PROSTATE  GLAND,  ETC.  363 

ous  bodies,  with  their  attaclimcnts  to  tlic  })n])i('  Imncs,  are 
roadilv  ('.\j)()sc(l.  The  urethra  is  (livi(le<l  transversely 
through  licaltliv  structure,  snipped  on  its  h)wer  surface, 
and  sutured  in  the  posterior  angle  of  the  wound  {perineal 
urrflirostomi/). 

The  cavernous  bodjes  of  the  penis  are  detached  and 
reflected  upward  in  conjunction  with  the  peripheral  por- 
tion of  the  urethra.  I^  the  detachment  has  been  extended 
to  die  pendulous  portion,  the  penis  is  after  circular  in- 
cision of  the  skin  divided  transversely  at  its  scrotal  at- 
tachment and  removed.  The  scrotal  wound  is  closed 
})y  suture  up  to  the  newly  established  orifice  of  the 
urethra. 

Operation  for  Urethral  Fistula. — As  long  as  the  fistulous 
passage  is  not  covered  over  by  skin  spontaneous  cure  can 
be  eifected  by  local  applications  conjoined  with  dilatation 
of  the  urethra.  Under  the  reverse  conditions,  and  if  the 
mucous  membrane  of  the  urethra  is  adherent  to  the  skin, 
freshening  of  the  margins  of  the  wound,  with  suture,  be- 
comes necessary  to  effect  a  cure.  If  the  fistula  be  small, 
an  elliptic  area  is  freshened  and  the  defect  is  closed  by 
transverse  deep  and  superficial  sutures  (Fig.  213).  In 
freshening  an  oval  area  the  formation  is  recommended  of 
lateral  flaps  by  means  of  incisions  made  on  either  side  close 
to  the  upper  and  lower  extremities  of  the  oval.  These 
flaps  are  detached  from  the  subjacent  structures  and  after 
the  introduction  <»f  l)uried  sutures  are  brought  together 
and  united  over  the  defect  (Fig.  214).  It  is  a  useful  pro- 
cedure further,  after  freshening  the  margins  of  the  fistula, 
to  separate  the  skin  from  the  mucous  membrane  through- 
out the  extent  of  the  defect  by  means  of  horizontal 
incisions,  so  that  the  margins  of  the  mucous  membrane 
can  be  ap])roxi mated  without  tension.  The  mucous  mem- 
brane is  united  over  the  defect  by  means  of  catgut  sutures, 
and  finally  the  wound  in  the  external  integument  is  closed. 
In  the  presence  of  an  extensive  defect  in  the  urethra  a 
tegumentary  flaj)  taken  from  the  penis  is  brought  over  the 
freshened  defect   in  such  a  way  that  its  cutaneous  aspect 


364 


OPERATIVE  SURGERY. 


is  turned  toward  the  lumen  of  the  urethra.     The  second 
step  consists  in  union  of  the  wound  in  the  skin. 

Under  the  best  of  circumstances  the  success  of  any  ope- 
ration for  urethral  fistula  will  be  rendered  disappointing 
by  reason  of  the  discharge  of  urine,  as  well  as  through 
erections,  with  tearing  out  of  the  sutures.  The  evacuation 
of  urine  interferes  with  the  process  of  healing  whether  a 
catheter  is  retained  or  spontaneous  micturition  takes  place. 


Fig.  213.— Urethral  fistula  :  elliptic 
fresheuiug ;  suture. 


Fig.  214.  —  Urethral  fistula: 
freshening,  with  the  formation  of 
lateral  flaps  ;  suture. 


In  the  performance  of  extensive  pkistic  oi)erations  upon 
the  penis,  therefore,  the  formation  of  a  provisional  vesical 
or  deep  urethral  fistula  during  the  time  of  healing  is  to  be 
recommended. 

Operations  for  Hernia. — Bloody  operations  for  hernia 
are  undertaken  for  the  purp(^se  of  either  releasing  an 
existing  strangulation  or  removing  a  free  or  adherent 
hernia  (radical  operation).     The  first  form  of  operation 


OPERA TIOSS    UruS   THE  PROSTATE  GLASD,  ETC.   365 

{herniotomy)  consists  in  division  of  the  coverings  of  the 
hernia,  openinir  of  the  hernial  sac,  and  division  of  the 
constricting  ring.  The  further  steps  of  the  operation 
(reposition  of  the  intestine,  formation  of  a  preternatural 
anus,  resection  of  the  bowel)  will  be  governed  bv  the  con- 
ditions present  in  the  individual  case.  The  cutaneous 
incision  is  made  in  the  longitudinal  axis  of  the  hernial 
tumor ;  in  the  presence  of  inguinal  hernia  in  such  a  man- 
ner that  the  inguinal  canal,  as  well  as  both  inguinal  rings, 
is  included  within  its  range.  In  the  presence  of  femoral 
hernia  the  vertical  incision  passes  over  the  greatest  con- 
vexity of  the  hernial  tumor.  By  careful  dissection,  layer 
by  layer,  after  division  of  the  subcutaneous  connective 
tissue  and  the  so-called  proper  fascia  of  the  hernia,  the 
hernial  sac  is  reached.  This  presents  a  dull  appearance, 
is  in  places  the  seat  of  small  masses  of  fat,  and  is  often  so 
delicate  that  the  hernial  fluid  can  be  seen  through  it.  In 
the  presence  of  inguinal  hernia  it  will  be  necessary' to  dh^ide 
in  the  upper  portion  of  the  hernial  tumor  the  anterior  wall 
of  the  inguinil  canal,  constituted  by  the  aponeurosis  of  the 
external  obli»pie  muscle  and  fibers  of  the  internal  oblique 
and  transversalis  muscles,  before  the  actual  coverings  of 
the  hernial  swellinir  are  reached.  The  sac  of  the  hernia  is 
in?ised  in  the  direction  of  the  cutaneous  incision,  and,  after 
the  hernial  fluid  has  been  permitted  to  escape,  the  removal 
of  the  constriction  is  undertaken.  In  the  presence  of  an 
inguinal  hernia  it  will  be  possible  always  to  expose  the 
constricting  ring  by  division  of  the  anterior  wall  of  the 
inguinal  wall  throughout  its  entire  extent  (Fig.  215). 
This  is  done  carefully  from  without  inward  until  all  ten- 
sion has  disappeared. 

In  the  case  of  femoral  hernia  division  of  the  constrict- 
ing band  is  effected  from  the  cavity  of  the  hernia  by 
means  of  a  blunt-pointed  knife,  or  herni^^tome,  under 
guidance  of  the  finder,  and  always  directed  inward.  The 
sharp  margin  of  Gimbernat's  lig-ament  is  incised  and  the 
constriction  is  thus  removed.  After  the  division  of  the 
constricting  band  has  been  effected  the  involved  loop  of 


366 


OPERATIVE  SURGERY. 


intestine  is  brought  forward  so  that  the  point  of  strangu- 
kition,  as  well  as  the  proximal  intestine,  may  be  seruti- 
nized.  If  the  serous  layer  is  smooth  and  lustrous,  the 
intestinal  loop  of  bowel  is  restored  to  the  abdominal 
cavity.     To  effect  reposition  the  loop  of  the  intestine  is 


Fig.  215. — Inguinal  hernia:  the  hernial  sac  is  opened  ;  the  outer  portion 
of  the  constricting  riug  is  exposed. 

gently  compressed,  so  that  any  contents  that  may  be 
present  may  escape.  By  means  of  pushing  movements 
with  the  fingers  the  loop  is  gradually  returned  to  the 
abdominal  cavity  through  the  hernial  opening.  During 
the  process  of  reposition  the  hernial  sac  is  held  tense. 


OPERATIONS   UPON  THE  PROSTATE  GLAND,  ETC.   367 

To  (M)nviii('(»  one's  self  that  the  bowel  has  been  actually 
replaced  in  the  abdominal  cavity  it  is  recommended  after 
reposition  has  been  effected  that  a  finger  be  introduced 
through  the  hernial  ring  into  the  al)doniinal  cavity  and 
be  swept  around  the  Internal  opening  of  the  hernial  canal. 
In  this  way  defective  reposition  or  apparent  reduction 
will  be  avoided. 

Prolapsed  omentum  is  either  simply  replaced,  or,  if  thickened,  is 
ligated  in  segments  and  removed.  If  the  contents  of  the  hernia  are  ad- 
herent to  the  inner  surface  of  the  hernial  sac  {adherent  hernia),  reposi- 
tion must  be  preceded  by  detachment  of  the  adhesions. 

If  the  serous  membrane  is  dull  at  the  line  of  strangulation,  the  loop 
of  intestine  is,  after  division  of  the  constricting  band,  left  in  the  wound. 
In  accordance  with  the  further  course  of  the  case  the  loop  may  be  re- 
placed after  the  lapse  of  several  days  or  a  preternatural  anus  may  be 
established. 

If  the  loop  of  intestine  prove  to  be  gangrenous  at  the  time  of  opera- 
tion, a  preternatural  anus  is  at  once  established,  the  bowel  being  sutured 
in  the  wound.  Another  procedure  in  the  presence  of  gangrene  of  the 
bowel  consists  in  primary  resection  and  union  by  circular  suture. 

If  a  fecal  abscess  have  already  formed,  it  is  opened  widely  and  the 
presenting  loops  of  intestine  are  secured  from  slipping  back  into  the 
abdomen  by  suture. 

The  last  step  of  the  operation,  closure  of  the  wound, 
demands  exact  approximation  of  the  hernial  canal,  with 
the  object  of  preventing  renewed  formation  of  a  hernia. 

Radical  Operation  for  Hernia. — Radical  operation  for 
hernia  may  be  performed  in  conjunction  Avith  herniotomy, 
and  is  besides  indicated  in  the  presence  of  adherent 
hernias  or  of  free  hernias  that  give  rise  to  discomfort  and 
cannot  be  retained  in  place  with  the  aid  of  trusses. 

Radical  Operation  for  Inguinal  Hernia. — The  radical 
operation  for  inguinal  hernia  has  for  its  object  closure  of 
the  hernial  canal  and  strengthening  of  the  inguinal  canal, 
which  after  the  operation  continues  to  serve  as  a  channel 
for  the  spermatic  cord,  so  that  it  will  offer  adequate 
resistance  to  the  intra-abdominal  pressure. 

The  inguinal  canal  comprises  the  interval  between  the  internal  and 
the  external  inguinal  ring  and  traverses  the  abdominal  wall  in  an 
oblique  direction,  downward  and  inward.  The  internal  op(Miing  of  tliis 
canal,  the  internal  inguinal  ring,  represents  the  entrance  of  the  ])rocess 
of  transversalis  fascia  extending  into  the  scrotum.  Tlie  external  in- 
guinal ring  is  formed  by  an  opening  in  the  aponeurosis  of  the  external 


368  OPERATIVE  SURGERY. 

Plate  22. — Bassini's  Operation  for  Inguinal  Hernia. 

I.  Exposure  of  the  aponeurosis  of  the  external  oblique  muscle  and 
the  external  inguinal  ring. 

II.  The  aponeurosis  of  the  external  oblique  muscle  is  divided,  as  well 
as  the  internal  oblique  and  transversalis  muscles ;  the  spermatic  cord  is 
retracted  and  at  the  bottom  of  the  wound  upon  the  peritoneum  the  epi- 
gastric vessels  can  be  seen  ;  the  layer  of  tissue  with  the  sharply  defined 
border  is  the  transversalis  fascia. 

oblique  muscle  just  above  Pou part's  ligament  to  the  outer  side  of  the 
tubercle  of  the  pubic  bone.  The  anterior  wall  of  the  inguinal  canal  is 
formed  by  the  aponeurosis  of  the  external  oblique  muscle  and  the  fibers 
of  the  internal  oblique  and  transversalis  muscles.  The  posterior  wall  is 
formed  mainly  by  the  transversalis  fascia  and  is  fortified  at  the  level  of 
the  external  inguinal  ring  by  muscular  bundles  from  the  internal 
oblique  and  transversalis. 

Steps  of  Bassini^s  Radical  Operafioii  for  Heiniia. — A 
cutaneous  incision  is  made  in  the  direction  of  the  inguinal 
canal,  from  the  neighborhood  of  the  internal  inguinal 
ring  and  passing  downward  beyond  the  external  inguinal 
rino^.     After  division  of  the  skin  and  the  subcutaneous 

c5 

connective  tissue  the  aponeurosis  of  the  external  oblique 
muscle  is  divided  in  the  direction  of  the  cutaneous  incision 
down  to  the  external  inguinal  ring  (Plate  22).  After  the 
thin  muscular  layer  of  the  internal  oblique  and  trans- 
versalis is  divided  in  the  same  direction  and  throughout 
the  same  extent,  the  structures  of  the  spermatic  cord, 
which  are  adherent  to  the  hernial  sac,  come  into  view. 
At  the  neck  of  the  hernial  sac  the  vas  deferens,  the 
artery  and  the  vein  of  the  spermatic  cord  are  detached 
from  the  sac  and  they  are  isolated  to  a  point  beyond  the 
hernial  ring.  The  hernial  sac  is  now  opened  at  its  fundus 
and  its  contents  are  restored  to  the  abdominal  cavity. 
While  the  hernial  sac  is  brought  forward  and  is  twisted 
at  its  neck  through  an  arc  of  180°  the  operator  passes  a 
ligature  around  the  neck  of  the  sac  and  tightens  it  as 
closely  as  possible  to  the  trunk.  The  hernial  .sac  is  di- 
vided transversely  with  a  single  stroke  of  the  scissors  at  a 
point  to  the  periphery  of  the  ligature  and  is  removed. 
There  remains  to  be  effected  the  re-establishment  of  a  new 


Tab.  2;i 


■^ 


OPERATIONS   UPON  THE  PROSTATE  GLAND,  ETC.   369 

InLiiilnal  canal  witli  tlioroiii^lily  i-csistant  walls.  If  the 
sjK'rmatic  cord  has  l)ccn  retracted  toward  the  median  line, 
and  if  the  two  margins  of  the  divided  ai)oneurosis  of  the 
external  obliqne  muscle  liave  been  displacred  upward  and 
downward,  there  will  a])])(>ar  in  the  wound  u])on  one  side 
the  groove  of  Poupart's  ligament  and  upon  tlu;  other 
side  the  outer  border  of  the  rectus  muscle,  together  with 
the  muscular  plate  formed  by  the  divided  internal  oblicpie 
and  transversalis  muscles.  This  muscular  layer  is  separ- 
ated by  blunt  dissection  from  the  subserous  tissues,  as  well 
as  from  the  aponeurosis  of  the  external  oblique,  so  that  it 
is  rendered  sufficiently  movable  to  be  brought  down  to 
Poupart's  ligament.  The  muscular  plate  named  is  attached 
to  the  posterior  border  of  Poupart's  ligament  by  sutures 
(Plate  23,  III).  The  sutures  on  the  pubic  bone  include 
also  the  external  border  of  the  rectus  muscle.  In  this 
way  a  posterior  muscular  wall  of  sufficient  resistance  is 
formed,  in  which  lies  the  newly  created  narrow  internal 
inguinal  ring.  The  spermatic  cord  is  })laced  upon  this 
muscular  layer,  and  over  it  the  aponeurosis  of  the  external 
oblique  is  closed  by  suture  except  at  its  lower  angle,  wOiich 
constitutes  the  new  external  inguinal  ring  (Plate  23,  IV). 
The  inguinal  canal  thus  formed  is,  after  healing  has  taken 
place,  so  resistant  that  the  use  of  a  supporting  truss  can 
be  dispensed  with. 

In  Kocher's  radical  operation  for  inguinal  hernia  (displacement- 
method)  the  cutaneous  incision  is  made  as  in  Bassini's  operation,  although 
the  aponeurosis  of  the  external  ol)lique  is  not  divided,  l)ut  slit  to  the 
outer  side  of  the  internal  inguinal  ring.  Through  this  opening  a  i)air 
of  forceps  is  introduced  and  j)assed  through  the  inguinal  canal  to  tlie  ex- 
ternal inguinal  ring.  The  apex  of  the  isolated  hernial  sac  is  grasped,  and 
drawn  outward  through  tlie  small  opening.  The  hernial  sac  is  drawn  so 
that  it  appears  sharply  l)ent  hackward  at  the  internal  inguinal  ring.  The 
portion  of  the  sac  lying  within  tlie  abdominal  wall  is  surroundi'd  and 
strongly  ligated.  The  hase  of  the  sac  thus  folded  together  is  attached 
to  the  outer  surface  of  the  aponeurosis  of  the  external  oblique  by  means 
of  deep  sutures,  and  the  remainder  is  removed. 

Radical  Operation  for  Femoral  Hernia. 

The  Femoral  Cnxnl. — The  interval  between  the  internal  and  the  ex- 
ternal femoral  ring,  whicli  constitutes  the  path  for  certain  varieties  of 
hernia,    is    known   as  the  femoral  canal.     Under    normal    conditions, 

24 


370  OPEBATIVE  SURGERY. 

Plate  23.— Bassini's  Operation  for  Inguinal  Hernia. 

III.  The  muscular  layer  of  the  internal  oblique  and  transversalis  is 
attached  by  suture  to  the  inner  border  of  Poupart's  ligament.  In  this 
way  the  internal  inguinal  ring  and  the  posterior  wall  of  the  inguinal 
canal  are  formed  anew. 

IV.  The  aponeurosis  of  the  external  oblique  is  united  over  the  sper- 
matic cord  except  in  the  situation  of  the  new  external  inguinal  ring. 

however,  this  canal  is  not  present  as  such.  The  inner  orifice  of  the  canal 
(internal  crural  ring)  lies  at  the  inner  angle  of  the  opening  for  the 
femoral  vessels,  between  Poupart's  ligament  and  the  horizontal  ramus  of 
the  pubis.  Thespace  is  bounded  within  by  the  free  border  of  Gimberuat's 
ligament  (fan-shaped  attachment  of  Poupart's  ligament  to  the  tubercle 
of  the  pubic  bone)  and  without  by  the  large  vessels  and  the  crural  vein. 
The  outer  orifice  of  the  crural  canal  corresponds  with  the  loose  connec- 
tive tissue  of  the  fascia  lata  (foramen  ovale)  through  which  the  saphenous 
vein  passes  to  enter  into  the  femoral.  The  tendinous  boundary  of  this 
opening  has  its  concavity  directed  toward  the  middle  line  and  is  known 
as  the  falciform  process. 

A  femoral  hernia,  after  passing  the  internal  craral 
ring,  enters  a  space  whose  floor  is  formed  by  the 
pectineal  fascia,  which  is  bounded  internally  by  Gimber- 
nat's  ligament,  externally  by  the  crural  vessels,  and  in 
Avhich  for  a  short  distance  the  upper  continuation  of  the 
ftlciform  process  forms  a  resistant  cover.  If  the  free 
border  of  this  be  passed,  the  hernia  can  push  before  it  the 
less  resistant  lamina  cribrosa  and  in  this  way  it  reaches 
the  exterior  through  the  foramen  ovale.  The  coverings  of 
a  femoral  hernia  are  thus  fewer  and  thinner  than  those  of 
an  inguinal  hernia.  The  hernial  sac  may  under  circum- 
stances, in  emaciated  subjects,  lie  just  beneath  the  subcu- 
taneous connective  tissue.  For  this  reason,  in  making  the 
cutaneous  incision,  especially  in  further  dissection  at  a 
depth,  great  care  will  be  required.  In  general  the  radical 
operation  consists,  after  making  a  cutaneous  incision,  in 
isolation  and  opening  of  the  liernial  sac.  Then  follow 
reposition  of  the  hernial  contents  and  ligature  of  the  neck 
of  the  sac,  with  or  without  torsion.  By  closure  of  the 
hernial  opening  through  suture  the  recurrence  of  the  dis- 
order is  to  be  prevented.  Radical  operation  for  the  relief 
of  femoral  hernia  is  rendered  difficult  by  the  fact  that  the 


Tnl^      9* 


fll. 


I\'. 


LUh.  A/tsl  r  Reichlwltl,  Miinclien 


OPERATIoyS   UPON  THE  rilOSTATE  GLAM>,  ETC.   371 

internal  opcninu;  of  the  canal  iy  funned  for  tliree-fonrths 
of  its  extent  of  tissues  (Ponpart's  ligament,  (iinihernat's 
ligament,  horizonal  ramus  of  the  pubis)  whose  resistance 
would  interfere  with  closure  of  the  hernial  opening. 

Mode  of  Fcrforiiiiiif/  the  Radical  Operaiion  for  Fe moral 
Hernia. — A  cutaneous  incision  is  made  by  the  method  of 
Bassini,  vertically  over  the  greatest  convexity  of  the 
tumor.  The  outer  surface  of  the  hernial  sac  and  the  fas- 
cia to  the  peripheral  side  of  the  swelling  are  exposed. 
The  body  and  the  neck  of  the  sac  are  isolated  to  a  point 
above  the  level  of  the  internal  crural  ring.  Isolation  of 
the  hernial  sac  upon  its  outer  side,  where  it  is  in  close 
relation  with  the  femoral  vein,  nuist  be  undertaken  with 
great  care.  The  hernial  sac  is  opened  and  its  contents 
replaced  after  separation  of  adhesions.  The  body  of  the 
hernial  sac  is  eh^vated,  twisted,  and  ligated  with  a  thread 
passed  around  its  neck.  The  sac  is  divided  transversely 
beyond  the  ligature.  After  replacement  of  the  stump  the 
hernial  ojiening,  the  plica  falciformis,  the  internal  open- 
ing, with  Giml)ernat's  ligament,  and  the  aponeurosis  over 
the  pectineal  crest  are  sufficiently  exposed.  Suture  begins 
close  to  the  pubic  tubercle  and  the  sutures  include  the 
pectineal  aponeurosis  and  the  posterior  inferior  portion  of 
the  internal  opening.  In  the  further  course  of  the  opera- 
tion the  border  of  the  falciform  process  is  united  with  the 
pectineal  fascia.  After  all  of  the  sutures  have  been 
introduced  they  are  tied,  beginning  with  the  innermost 
and  uppermost.  The  line  of  suture  pursues  the  course  of 
an  oblique  C. 

Fabricius  closes  the  hernial  opening  by  suture  in  cases  of  femoral 
hernia  after  the  fat  as  well  as  the  lymphatic  glands  present  in  the  fem- 
oral canal  are  removed  in  such  a  way  that  Poupart's  ligament  is  relaxed 
and  is  attached  by  periosteal  sutures  to  the  horizontal  branch  of  the 
pubic  bone. 

Umbilical  Hernia,  Radical  Operation.  Operation  for  In- 
carcerated Omphalocele. — The  usual  procedure  consisted 
until  recently  in  closure  of  the  hernial  opening  by  suture 
after  opening  the  hernial  tumor  and  replacement  of  the 


372  OPERATIVE  SURGERY. 

intestine.  Greater  security  against  the  recurrence  of  the 
hernia  and  a  more  thoroiigii  inspection  during  the  opera- 
tion are  aiforded  by  excision  of  the  umbilical  ring  {omph- 
aledorni/,  Condamin,  Bruns).  The  umbilical  region  is 
surrounded  by  two  elliptic  incisions,  each  of  which  ex- 
tends to  the  inner  l)order  of  the  rectus  muscle  and  opens 
the  abdominal  cavity  on  either  side  of  the  hernial  ring,  so 
that  the  entire  hernial  tumor,  together  with  the  neck  of 
the  hernial  sac,  is  removed.  If,  in  addition,  a  portion  of 
the  sac  is  divided  from  the  margin  of  the  Avound  through 
the  hernial  opening,  the  entire  contents  of  the  hernia  are 
exposed  to  view.  In  this  way  satisfactoiy  scrutiny  of  the 
conditions  present  is  possible,  inasmuch  as  the  abdominal 
viscera  are  rendered  visible,  both  prior  to  the  entrance 
into  the  hernia,  as  well  as  within  the  hernial  sac.  Adhe- 
sions that  may  be  present  are  separated,  and  any  existing 
strangulation  can  be  freed  in  the  open  wound.  After  re- 
placement of  the  intestines  the  abdominal  Avound  is  care- 
fully approximated  by  interrupted  sutures  in  three  layers, 
the  first  including  the  serous  membrane,  the  second  the 
recti  muscles  and  sheaths,  and  the  third  the  skin. 

Ligation  of  the  Iliac  Artery. — At  the  level  of  the  fourth 
lumbar  vertebra  the  aorta  divides  into  the  two  iliac  arte- 
ries, each  of  which  in  turn  divides  at  the  sacro-iliac  articu- 
lation into  two  branches,  the  external  and  internal  iliac 
arteries.  The  external  iliac  arters',  the  abdominal  por- 
tion of  the  femoral,  passes  along  the  outer  side  of  the 
corresponding  vein  along  the  psoas  muscle  to  the  opening 
beneath  Poupart's  ligament  for  the  vessels.  The  internal 
iliac  artery,  also  known  as  the  hypogastric,  passes  from 
the  sacro-iliac  symphysis  down  into  the  pelvis,  to  supply 
the  organs  of  this  cavity,  as  well  as  the  gluteal  muscles 
and  the  genitalia,  with  blood. 

Ligation  of  the  External  Iliac  Artery. — The  artery-  is 
exposed  in  the  subserous  space  just  prior  to  its  entrance 
into  the  opening  for  the  vessels.  The  cutaneous  incision 
is  made  parallel  with,  and  over  the  middle  of,  Poupart's 
ligament,  and  the  fascia  of  the  external  obliq^ue  muscle, 


OPERATIOSS   UPON  THE  PROSTATE  GLAND,  ETC.  373 

the  fibers  of  the  internal  ol^licjue  and  transversalis  are 
divided  in  thedireetion,  and  throii^rhout  the  extent,  of  this 
ineision.  Alter  divi.^ion  of  the  transversalis  faseia  the 
subserous  fat  and  the  peritoneum  are  ex})osed  to  view. 
The  peritoneum  is  se})arate(l  by  blunt  disseetion  from 
Poupart's  li*iament  and  the  pelvie  margin,  after  whieh 
the  external  iliae  vessels  surrounded  by  loose  connective 
tissue  become  visible  upon  the  floor  of  the  wound.  The 
artery  (the  vein  lies  to  its  inner  side)  is  isolated  Ijy  l)lunt 
disseetion  with  the  aid  of  two  anatomic  forceps  (Plate  24). 

In  ligating  the  internal  iliac  artery  the  cutaneous  in- 
cision passes  from  the  apex  of  the  last  rib  vertically  down- 
ward to  the  crest  of  the  ilium  and  along  this  almost  to 
the  anterior  superior  iliac  spine.  The  layers  of  the 
abdominal  wall  and  the  transversalis  fascia  are  divided, 
the  peritoneum  separated  by  blunt  dissection  from  the 
iliac  fossa  and  displaced  toward  the  median  line  by  means 
of  broad  spatula?  or  the  palm  of  the  hand.  Between  the 
iliac  and  psoas  muscles  the  external  iliac  artery  is  visible 
and  can  be  followed  in  a  proximal  direction  as  far  as  the 
sacro-iliac  symphysis,  where  the  internal  iliac  artery  is 
accessible  as  it  branches  off  toward  the  pelvis  and  can  be 
isolated  for  ligature.  The  vein  lies  to  the  inner  side  of 
the  artery.  The  mode  of  procedure  just  described  serves 
also  for  exposing  the  common  iliac  artery. 

The  manner  of  exposing  the  iliac  vessels  constitutes  in 
general  the  mode  of  procedure  in  accordance  with  which 
the  structures  of  the  subserous  space  are  reached.  The 
incision  for  ligation  of  the  internal  iliac  artery  exposes  the 
kidney  and  the  ureter  in  its  course.  In  the  same  way  it 
is  possible,  with  conservation  of  the  peritoneum,  to  evacu- 
ate accumulations  of  ]nis  in  the  subserous  space  (psoas 
abscess,  paratyphlitic  abscess,  parametric  abscess). 

If  after  opening  the  abdominal  cavity  by  celiotomy  the 
parietal  peritoneum  upon  the  posterior  wall  of  the  abdo- 
men is  divided  and  in  this  way  the  retroperitoneal  space 
is  exposed,  the  procedure  is  designated  transperitoneal  ex- 
posure of  the  iliac  artery,  of  the  kidney,  of  the  ureter, 


374  OPERATIVE  SURGERY. 

Plate  24.— Exposure  of  the  External  Iliac  Artery. 

There  are  divided  the  aponeurosis  of  the  external  oblique  muscle 
(Q.e.),  the  fibers  of  the  internal  oblique  {Q-i.),  and  the  transversalis 
fascia  (F.t.)\  the  peritoneum  (P)  is  separated  by  blunt  dissection  and 
raised  up ;  the  iliac  artery  and  vein  are  exposed  in  the  subserous  space. 

etc.  Under  these  conditions  the  peritoneum  must  be 
divided  at  two  corresponding  points  on  the  anterior  and 
the  posterior  abdominal  walL 

Operations  on  the  Kidneys. — Operations  on  the 
kidneys  may  be  undertaken  : 

1.  For  the  purpose  of  opening  the  kidney  by  incision 
— nephrotomy  ; 

2.  For  the  removal  of  the  totally  diseased  kidney — 
nephrectomy  ; 

3.  For  fixation  of  a  movable  kidney — nepjhropexy  ; 

4.  For  the  exsection  of  portions  of  the  kidney — resec- 
tion of  the  kidney. 

Nephrotomy  and  Nephrectomy. — Nephrotomy  is  indi- 
cated in  the  presence  of — 1,  simple  pyonephrosis ;  2, 
stones  in  the  pelvis  of  the  kidney,  if  sufficiently  function- 
ally active  parenchyma  remain ;  3,  severe  renal  hematuria; 
4,  hydronephrosis. 

Nephrectomy  is  indicated  in  the  presence  of:  1,  severe 
pyonephrosis,  if  the  kidney  is  transformed  into  a  series  of 
pus-cavities  (calculosis,  tuberculosis  of  the  kidney) ;  2,  in- 
juries of  the  kidney  (rupture,  laceration) ;  3,  tumors  of 
the  kidney ;  4,  incurable  ureteral  fistulse. 

For  exposure  of  the  kidney  the  patient  is  placed  upon 
the  healthy  side  of  his  }x)dy  over  a  pillow.  The  cuta- 
neous incision  begins  at  the  twelfth  rib  and  passes  thence 
vertically  downward  toward  the  crest  of  the  ilium  and 
along  this  almost  to  the  anterior  superior  spine.  Skin, 
fat,  lumbodorsal  fascia,  the  fibers  of  the  latissimus  dorsi 
are  divided,  in  order  that,  after  division  of  the  deep  layer 
of  the  fascia,  the  quadratus  lumborum  and,  in  the  anterior 
portion  of  the  wound,  the  triplicate  layer  of  the  abdominal 
muscles,  may  be  divided.     After  the  transversalis  muscle 


Tab.  24. 


Lith^  Arist  E  Reichhvld.  Mimchen . 


OPERATIONS  ON  THE  KIDNEYS.  375 

also  liiis  \wvn  j)mss(>(1  tlio  fiitty  ca[).sulc  of  the  kidney  is 
exposed  tliroiiohont  u  suHieient  extent.  This  eai).sule  is 
divided  and  the  kichiey  is  removed  from  its  bed  by  bhmt 
disseetion  with  tlie  tinger  until  the  organ,  eompletely  freed 
at  all  points  with  the  exeeption  of  its  hilus,  can  be 
brought  by  traction  to  the  level  of  the  wound. 

For  exploration  of  tlie  pelvis  of  the  kidney,  for  the 
removal  of  stones  from  the  pelvis,  et<;.,  the  kidney  is 
opened  from  its  eonvex  border.  An  incision  is  made 
u])on  the  convexity,  through  the  renal  parenchyma,  down 
to  the  pelvis  of  the  kidney,  large  enough  to  permit  the 
introduction  of  the  index-finger,  with  which  the  pelvis  is 
examined.  If  necessary,  this  incision  may  be  extended 
toward  the  poles  of  the  organ  to  a  maximum  degree 
until  the  kidney  can  be  separated  in  two  halves.  This 
procedure  is  carried  out  with  digital  compression  of  the 
large  vessels  at  the  hilus  of  the  kidney.  If  the  conditions 
are  so  constituted  that  primary  union  can  take  place,  the 
wound  in  the  kidney  is  closed  by  deep  and  superficial  in- 
terrupted catgut  sutures,  the  organ  dropped  into  place,  and 
the  cutaneous  wound  closed,  except  for  a  small  opening  for 
a  drainage-tube.  Provisional  suture  of  the  wound  in  the 
kidney  for  the  control  of  hemorrhage  may  also  be  under- 
taken if  in  immediate  conjunction  with  an  exploratory 
incision  the  removal  of  the  entire  organ  is  determined 
upon.  After  extirpation  of  the  kidney  the  large  vessels 
at  its  hilus  must  be  exposed  and  carefully  ligated.  If 
possible,  the  kidney  is  drawn  forward  and  the  artery  and 
the  vein  are  isolated  at  the  hilus  (Fig.  216).  If  this  is 
not  possible,  the  operator  grasps  the  hilus  of  the  organ 
with  the  thumb  and  index-finger  of  the  left  hand  and 
witli  the  guidance  of  this  hand  a])plies  a  clamp-forceps 
around  the  entire  pedicle.  The  pedicle  is  divided  beyond 
the  grasp  of  the  forceps  with  scissors  and  ligated  en  masse 
upon  the  proximal  side.  The  large  vessels  exposed  in 
the  transverse  incision  are  further  isolated  and  ligated 
separately. 

The  large  wound-cavity  is  closed  after  perfect  control 


1^76 


OPERATIVE  SUHGERY. 


of  hemorrhage,  drained,  and  the  wound  closed  by  sutures 
in  tiers  (muscles,  fascia,  skin). 

To  effect  operative  fixation  of  a  movable  kidney  (nephro- 
pexy, nephrorrhaphy)  the  organ  is  exposed  in  the  usual 
manner,  the  sutures  (ten  or  twehe)  for  the  fixation  of  the 
organ  being  passed  deeply  through  its  parenchyma  and 
placed  in  the  upper  angle  of  the  cutaneous  incision  on 


% 

■"'TV;''.      I'"l 

* 

m 

Fig.  216. — Lumbar  incision  :  the  kidney  is  brought  out  of  the  wound 
in  the  abdominal  wall  and  the  structures  of  the  hilus  of  the  organ  are 
isolated  and  exposed  for  ligature. 

either  side  and  tied.  In  this  manner  the  kidney  is  suitably 
located  and  fastened.  The  method  of  retroperitoneal  ex- 
posure of  the  kidney  described  affords  as  a  rule  sufficient 
access  to  the  organ.  In  the  presence,  howeyer,  of  large 
diffusely  adherent  tumors  of  tlie  kidney,  or  in  the  case  of 
adipose  indiyiduals,  it  may  be  necessary,  to  afford  greater 
accessibility,  to  make  from  the  middle  of  the  lumbar  in- 
cision a  transyerse  incision  passing  toward  the  umbilicus. 


OPERATIONS  ON  THE  KIDNEYS.  Z11 

Bardeiiheuer  recoininonds  the  so-called  (rajj-door  incision.  From  the 
upi)or  and  lower  extifinitics  of  the  vertical  longitudinal  incision  i)assinK 
from  the  costal  arch  to  tlu-  middle  ol"  the  crest  of  the  ilium  transverse 
incisions  are  made  aloui^  tlu-  rib  and  the  iliac  crest.  IJardenheuer  makes 
three  forms  of  trap-door  incision,  an  anterior,  |  ,  a  posterior,  ^^,  and 
a  two-sided  one,  ~i~. 

Ill  contradistinction  from  the  retroperitoneal  method 
described  is  the  transpe;ntoneal  method  for  exposing  the 
kidney.  In  this  latter  operation  tlie  a1)d()minal  cavity  is 
opened  in  the  usnal  manner  in  the  linea  alba,  the  peri- 
tonenni  over  the  kidney  is  divided,  and  the  organ  is 
enucleated  out  of  its  bed.  The  retroperitoneal  method 
has,  on  the  (Ulier  hand,  the  advantage  of  permitting,  iii 
conjunction  with  an  exploratory  procedure,  of  the  estab- 
lishment of  a  renal  fistula,  of  the  drainage  of  an  abscess 
of  the  kidney  under  favorable  conditions,  as  well  as  total 
removal  of  the  entire  organ. 

Operations  on  the  Ureters. — The  ureter  passes  from  the 
kidney  on  either  side  in  the  subserous  space  just  behind 
the  peritoneum  to  the  fundus  of  the  bladder.  In  its 
upper  portion  it  lies  upon  the  psoas  muscle,  crossing  at  its 
entrance  into  the  pelvis  the  point  of  division  of  the  com- 
mon iliac  artery  and  entering  the  pelvis  in  a  direction  for- 
ward and  inward  to  reacli  the  base  of  the  bladder.  Most 
commonly  injuries  of  the  ureter  in  the  course  of  opera- 
tions furnish  the  indication  for  operations  upon  this  struct- 
ure ;  less  commonly  impaction  of  stones  in  the  ureter, 
.occlusion  of  the  lower  extremity  of  the  ureter  from  the 
presence  of  a  neoplasm,  or  kinking  of  the  ureter  in  cases 
of  hydronephrosis. 

Of  operations  tliere  have  been  performed  :  linear  open- 
ing of  the  ureter  for  delivery  of  a  stone,  with  subsecjuent 
suture  of  the  incision  (ureteroUthofomi/)  ;  the  displace- 
ment of  a  stone  present  along  the  ureter  into  the  ])elvis 
of  the  kidney  ;  and,  finally,  digital  attrition  of  soft  stones 
without  opening  the  ureter.  In  the  presence  of  injuries 
of  the  ureter,  restoration  of  the  lumen  of  the  tube  by 
suture  of  the  stumps  or  grafting  of  the  central  stump  of 
the  ureter  into  a  neiffliboriup;  oroan  mav  be  undertaken  to 


378 


OPERATIVE  SURGERY. 


effect  closure  of  ureteral  fistuhe.  With  this  eud  in  view 
the  ureter  has  been  united  w  ith  the  bowel  {uretero-enter- 
ostomy),  with  the  ureter  of  tlie  opposite  side  (uretcro- 
iireterostomy) ,  and  with  a  new  portion  of  the  bladder 
(iiretero-neocystostomy).     Anastomosis  of  the  ureter  with 


-LUUi'Jf  J>-J'-#---J-  -■^. 


Fig.  217. — Invagination-suture  of  the  stumps  of  the  divided  ureter. 

the  bowel  has  also  been  undertaken  for  the  correction  of 
ectopy  of  the  bladder  (Maydl).  Circular  union  of  the 
transversely  or  obliquely  divided  stumps  of  the  ureter  has 
the  disadvantage,  in  view  of  the  narrow  caliber  of  the 
ureter,  of  being  followed  by  such  contraction  of  the 
cicatrix  as  to  result  in  narrowing  of  the  lumen  of  the  tube. 


OPEBATIOyS   UPON  THE  RECTUM  AND  ANUS.     379 

For  this  reason  the  invagiiuition-.siiturc  of  A  an  Hook  is 
to  1)1'  prcicrrctl.  The  free  end  of  the  peripheral  stump  is 
closed  l)y  a  ligature,  2.5  mm.  below  whieh  a  longitudinal 
incision  is  made  through  the  thickness  of  the  wall  oi"  the 
uretei'.  The  central  stump  is  caught  with  a  catgut  suture, 
the  ends  of  which  are  carried  by  means  of  a  needle 
through  the  longitudinal  incision  in  the  ])eripheral  stump, 
the  needle  being  further. passed  through  the  opposite  wall 
of  this  stump.  By  gentle  traction  on  the  suture  the 
centml  stump  of  the  ureter  is  drawn  through  the  slit  in 
the  peri])heral  portion,  and  fastened  in  position  by  knot- 
tino-  the  thread  in  this  situation.  A  few  additional  sutures 
on  the  outer  side  insure  contiguity  of  the  stumps  (Fig. 
217). 

In  the  practice  of  implantation  of  the  ureter  by  the 
method  of  l^iidinger  and  M'itzel  a  normal  canal  is  formed 
in  which  the  ureter  is  contained  (oblique  fistula),  thus 
most  nearly  imitatino;  the  natural  mode  of  entrance  of 
the  ureter.  The  divided  ureter  is  implanted  in  the 
wall  of  the  selected  organ  in  the  same  manner  as  is  the 
rubber  tube  in  WitzeFs  operation  of  gastrostomy,  and  is 
fixed  in  position  by  suture.  For  exposure  of  the  upper 
portions  of  the  ureter  the  lumbar  incision,  as  for  neph- 
rectomy, may  be  made  advantageously.  The  pelvic  por- 
tion of  the  ureter  in  the  male  is  accessible  through  the 
sacral  route  after  enucleation  of  the  coccyx  and  avoidance 
of  the  rectum. 

Operations  upon  the  Rectum  and  the  Anus. — 
Amputation  and  Resection  of  the  Rectum. — Operations  for 
the  removal  of  tumors  of  the  rectum  will  vary  with  the 
seat  and  the  extent  of  the  morbid  process.  Circumscribed 
or  pedunculated  tumors  are  surrounded  by  incisions  at 
their  base,  and  severed  through  healthy  tissue,  the  wound 
created  being  closed  by  suture.  It  is  difficult  in  the  treat- 
ment of  cases  of  this  kind  to  expose  sufficiently  the  field 
of  operation.  For  more  deeply  seated  tumors,  in  the  re- 
gion of  the  anus,  it  is  sufficient  to  distend  this  portion  of 
the    bowel   by  means  of  retractors  or   suitable   specula. 


380  OPERATIVE  SURGERY. 

Tiiiiiors  seated  high  up  require  as  a  preliuiinarv  operation 
linear  division  of  the  sphincter^  which  is  practised  on  the 
anterior  and  posterior  aspects  along  the  line  of  the  raphe, 
with  marked  retraction  of  the  margins  of  the  wound,  and 
renders  accessible  to  the  knife  the  portions  of  the  rectal 
mucous  membrane  above  tlie  sphincter.  The  anterior 
wall  of  the  rectum  can  be  reached  with  the  aid  of  a  pre- 
rectal  incision  by  separation  of  the  rectum  from  the 
urethra  (see  Prostatotomy).  By  this  means  the  entire 
thickness  of  a  circumscribed  portion  of  the  wall  of  the 
rectum  can  be  resected  and  the  defect  be  closed  by  suture. 
If  the  neoplasm  involve  the  entire  periphery  of  the  lowest 
portion  of  the  rectum  a  circular  incision  is  made  around 
the  anus  and  tlie  lower  extremity  of  the  rectum  is  freed 
from  its  surroundings.  The  rectum  is  then  divided  trans- 
versely upon  the  proximal  side  of  the  neoplasm.  The 
wound  is  so  adjusted  that  the  stump  of  the  rectum,  brought 
to  the  level  of  the  surface,  is  fixed  to  the  skin  by  sutures 
passing  through  all  the  layers  of  the  wall  of  the  bowel. 
This  method  of  amputation  has  a  limited  field  of  applica- 
tion. If  the  upper  border  of  the  tumor  can  he  reached 
with  the  palpating  finger,  its  removal  by  the  method  de- 
tailed can  be  technically  carried  out ;  but  isolation  of  the 
rectum  in  its  upper  portions  and  access  to  the  sigmoid 
flexure  are  quite  impossible  by  this  mode  of  procedure. 
The  cutaneous  wound  allows  of  limited  access,  so  that 
certainty  in  operation,  especially  control  of  hemorrhage  in 
the  higher  portions  of  the  wound,  encounters  irremovable 
obstacles. 

Resection  of  the  rectum^  with  union  of  the  stumps  of  the 
intestine,  l)y  tlie  method  described,  is  difficult  even  if 
access  is  afforded  by  anterior  and  posterior  incisions 
througli  the  raphe,  also  when  the  tumor  is  deeply  seated, 
and  entirely  impossible  if  this  be  situated  in  tlie  upper 
portion  of  the  rectum. 

The  limits  of  operability  of  tumors  of  the  rectum  were 
enlarged  materially  with  atteni])ts,  on  Kraske's  sugges- 
tion, to    expose   the  rectum  sufficiently  and  also  in   its 


OPERATIOSS   UPON  Till':  IlhVTUM  AND  ANUS.     381 

liiiiluT  jxuMion  tliroiinh  tlic  sacral  route  It  is  possible  by 
tills  mode  ol'  priK'ediire  to  isolate  tiie  reetiiin  even  to  its 
intraperitonetil  portion  and  to  praclise  resections  of  this  j)or- 
tion  of  the  l)()\vel  in  its  continuity,  w  ith  an  adeijuate  lield 
of  (yperation.  The  rectum  is  reached  from  the  posterior 
aspect  after  division  of  the  sacrotuherous  and  sacrospinous 
liiraments  through  the  wide  interval  on  either  side  between 
the  margin  of  the  sacrum,and  the  tuberosity  of  the  ischium. 
The  accessibility  is  increased  by  removal  of  a  portion  of 
the  mariiin  of  the  sacrum  with  a  chisel. 

Mode  of  Kffivthig  Sdcral  Krposurc  of  the  Rectum 
(HochenejriJ:). — The  patient  occupies  the  left  lateral  decu- 
bitus with  the  lower  extremities  flexed  at  the  hips  and 
the  knees  and  the  operator  standing  back  of  the  patient. 
The  cutaneous  incision  begins  at  the  middle  of  the  left 
sacro-iliac  symphysis  and  passes  over  the  middle  line  in 
an  arc  whose  convexity  is  directed  toward  the  right  and 
terminates  below  the  apex  of  the  coccyx  ;  or,  if  the  anal 
portion  also  is  to  be  removed,  it  surrounds  the  anus  ellip- 
tical 1  v.  The  incision  is  deepened  down  to  the  bone.  The 
soft  parts  are  retained  in  connection  with  the  skin  and  are 
dissected  from  the  bone  so  that  the  left  half  of  the  sacrum 
and  the  coccyx  are  exposed  in  the  wound.  After  enuclea- 
tion of  the  coccyx  access  to  the  rectum  will  be  already 
relatively  free  and  it  becomes  considerably  greater  after 
division  of  the  attachments  of  the  sacrotuherous  and  sacro- 
spinous ligaments.  The  extensive  field  of  operation  thus 
exposed  ])ermits  of  careful  scrutiny  with  regard  to  the 
extent  and  limits  of  the  tumor,  and  even  of  the  higher 
portions  of  the  rectum,  not  accessible  through  the  usual 
modes  of  procedure.  Further  extension  of  the  field  of 
o]ieration  can  be  effected  by  chiselling  the  left  margin 
of  the  sacrum. 

After  exposure  of  the  rectum  the  second  step  of  the 
operation — that  is,  isolation  of  the  tumor  beyond  its  limits 
— is  undertaken.  The  rectum  is  separated  from  its  sur- 
roundings by  blunt  dissection  and  the  visible  vessels  are 
ligated  in  the  wound.     If  high  amputation  of  the  rectum 


382  OPERATIVE  SURGERY. 

is  to  be  performed,  the  stump  of  the  bowel  is  brought 
clown  and  fastened  to  the  skin  in  the  upper  angle  of  the 
wound  (sacral  preternatural  anus).  This  procedure  is 
indicated  when  the  anal  portion  is  involved  in  the  new- 
growth  and  must  be  removed  in  connection  therewith. 
If,  on  the  other  hand,  the  anal  portion  is  healthy,  the 
tumor  being  seated  in  the  middle  portion  of  the  rectum, 
the  bowel  on  either  side  of  the  morbid  process  is  isolated 
by  blunt  dissection  into  healthy  tissue,  ligated  and  re- 
moved by  resection.  The  two  stumps  of  the  intestine  are 
united  either  primarily  tln'oughout  their  entire  extent,  or 
sutured  only  partially,  so  that  a  provisional  artificial  anus 
is  formed.  This  forms  a  mural  fistula,  Avhich  may  either 
close  spontaneously  or  be  closed  after  a  time  by  a  plastic 
operation.  In  introducing  the  sutures,  both  stumps  must 
be  approximated  without  any  tension.  In  the  isokition 
of  tumors  seated  high  up  it  is  often  necessary  to  open  the 
peritoneum  of  the  vesicorectal  cul-de-sac.  The  proximal 
stump  of  the  rectum  is  brought  into  the  wound  for  the 
formation  of  an  artificial  anus  or  for  suture  and  the  ante- 
rior lip  of  the  peritoneal  wound  is  united  at  a  suitable 
level  with  the  serous  layer  of  the  intestine,  so  that  the 
abdominal  cavity  is  walled  off'  from  the  AAound.  After 
the  introduction  of  circular  intestinal  sutures  a  large 
drainage-tube  is  introduced  tlirough  the  anus  into  the 
rectum  beyond  the  line  of  suture. 

Operations  for  Rectal  Fistula. — Rectal  fistula  can  be 
made  to  heal  by  division  of  the  fistulous  tract  and  the 
conversion  of  the  tubular  ulcer  into  an  open  wound.  In 
the  operation  for  complete  fistula  a  slender  probe  is  intro- 
duced through  the  external  fistulous  opening,  Avhile  the 
index-finger  "of  tlie  left  hand  is  applied  to  the  internal 
opening,  which  often  is  appreciable  as  a  loss  of  substance. 
The  probe  is  thus  passed  through  tlie  tract  and  enters  the 
lumen  of  the  bowel.  A  grooved  director  may  be  readily 
passed  through  the  fistula  by  the  side  of  tlie  probe  into 
the  rectum  and  its  extremity  brought  out  through  the 
anus.    The  soft  parts  covering  the  fistula  thus  come  to  lie 


OPlJRATrONS   UPON  TlIK  RECTUM  AND  ANUS.     383 

upon  the  director,  upon  wliicli  tlicy  are  divided  with  the 
knil'e.  lly  the  iiitrodiietioii  oi"  teiiacuhi  niter  division  of 
the  tissues  the  eharacter  of  the  lining  of  the  fistulous  tract 
ean  he  rendered  visible.  As  a  rule,  the  wound  is  ])er- 
mitted  to  heal  hy  <»;ranulation,  although  after  extirj)ation 
of  the  entire  fistulous  })assage  the  wound  can  be  closed 
completely  by  suture. 

Ineoni])lete  fistuhe  nfust  be  converted  into  complete 
Hstuhe  before  being  divided.  In  the  presence  of  an  in- 
complete external  fistula  the  grooved  (lire(;tor  is  intro- 
duced and  pushed  into  the  rectum  through  the  deepest 
portion  of  the  fistula.  Division  of  the  fistula  thus  made 
complete  is  effected  in  the  manner  (lescril)ed.  In  the 
presence  of  an  incomplete  internal  fistula,  with  its  open- 
ing upon  the  mucous  membrane  of  the  rectum  the  sound 
or  the  grooved  director  is  introduced  from  the  rectum 
toward  the  skin.  When  the  head  of  the  probe  is  felt 
beneath  the  skin  an  incision  is  made  down  npon  it  and 
the  complete  fistula  thus  established  is  divided  in  the 
manner  described.  In  the  presence  of  extensive  fistulous 
formations  it  becomes  necessary  to  follow  the  manifold 
ramifs'ing  passages  often  present  and  to  open  them 
adequately. 

Operation  for  Hemorrhoids. — Dilatations  of  the  external 
hemorrhoidal  veins  do  not  require  operatives  treatment. 
Operation  is  indicated  only  in  those  cases  of  dilatation  of 
tli(,'  internal  hemorrhoidal  veins,  with  consecutive  changes 
in  the  mucous  membrane,  in  which  prolapse  of  the  mucous 
membrane  of  the  rectum  has  taken  place,  Avhich  makes 
itself  apparent  either  only  npon  increased  abdominal 
pressure  or  habitually  as  a  result  of  this  influence.  The 
prolapsed  masses  of  mucous  membrane  are  either  destroyed 
with  the  actual  cautery,  or  subjected  to  atrophy  through 
the  elastic  ligature,  or  excised  by  a  bloody  operation. 

Caufeiizdtiou. — The  patient  occupies  the  position  as  in 
the  operation  for  stone,  or  the  lateral  decubitus.  By 
means  of  digital  dilatation  of  the  anus  the  hemorrhoidal 
masses  are  exposed  to  view.     They  are  grasped  in  seg- 


384  OPERATIVE  SURGERY. 

ments  with  a  clanip-forceps  and  their  base  is  surrounded 
by  Langenbeck's  flat  forceps.  The  tumor  lying  upon  the 
broad  ivory  plate  of  the  forceps  is  totally  destroyed  with 
the  tip  of  the  Paquelin  cautery^  after  which  the  forceps  is 
carefully  removed.  In  the  same  manner  the  swellings 
throughout  the  entire  circumference  of  the  rectum  are 
destroyed. 

EUiatic  Ligature. — The  patient  occupies  the  lateral 
decubitus.  By  means  of  a  clamp  polyp-forceps  the  ex- 
truded mass  of  mucous  membrane  is  grasped  at  its  base 
and  brought  forward.  The  elastic  ligature  is  passed 
around  the  neck  of  the  nodule  behind  the  forceps  and 
tightened  and  the  nodule  fixed  by  means  of  a  silk  thread 
tied  around  it.  In  this  way  the  whole  series  of  folds  is 
included  in  three  or  four  parts  and  ligated.  The  necrotic 
nodules  are  thrown  off*  in  the  course  of  a  week. 

Excision  may  l)e  practised  upon  each  nodule  individ- 
uallv,  or  a  circular  incision  is  made  through  the  skin 
around  the  anus  and  also  through  the  mucous  membrane 
of  the  rectum  above  the  level  of  the  nodules.  The  cylin- 
der of  mucous  membrane,  together  with  the  dilated  veins, 
is  dissected  free  from  the  sphincter  and  the  margin  of 
the  mucous  meml)rane  is  united  by  suture  with  the  skin 
at  the  anus. 

Operation  for  Atresia  of  the  Anus. — The  incision  is 
made  in  the  perineal  raphe  from  the  apex  of  the  coccyx 
to  the  root  of  the  scrotum  (posterior  commissure).  The 
operator  advances  into  the  depth  layer  by  layer,  always 
keeping  strictly  in  the  middle  line.  As  a  rule,  the  bluish- 
colorerl  cul-de-sac  of  the  rectum  is  soon  reached,  and  it  is 
incised  in  the  direction  of  the  cutaneous  incision.  After 
the  meconium  has  been  discharged  the  bowel  is  united 
throughout  its  entire  periphery  to  the  skin  by  sutures  pass- 
ing through  the  entire  thickness  of  the  wall  of  the  intes- 
tine. If  the  cul-de-sac  be  situated  high  up,  an  effort 
should  1)6  made  to  reach  the  rectum  by  the  sacral  route. 
In  the  presence  of  atresia  ani  vesicalis,  vaginalis,  an 
attempt  is  made  to  dissect  free  the  lower  end  of  the  intes- 


OPKliATloSS    I' PON  THE  RECTUM  AND  ANUS.     385 

tine  l)y  iiicims  oi'  the  same  incision.  Tlic  ahnorniiil  com- 
nnniicalion  is  divided  with  scissors  and  the  rectum  is 
fixed  in  tile  \\<nMi(l  by  sutures  in  the  manner  described. 
Tlie  detect  in  tlie  vaiiina  or  the  hhiddcr  made  by  the 
se})aration  of  the  rectum  nmst  have  been  closed  pre- 
viously by  suture. 
25 


INDEX. 


Abdominal  puncture,  307 
Abscesses,  perineal,  opening  of,  321 
Achillotenotoniy,  132 
Actual  cautery,  39 
Air-passages,  operations  on,  274 
Amputation,  bh 

by  circular  incision,  83 

by  flap-incision,  96,  Figs.  59-62 

by  oval  incision,  108 

circular,  88 

control  of  hemorrhage  after,  109 

control  of  hemorrhage  in,  87 

division  of  the  bone  in,  108 

flap,  96 

steps  of,  88 
indications  for,  86 
knives,  18 
of  arm,  184,  PI.  11 
of  finger  through  metacarpus,  174  ; 
of  foot  at  tarsometatarsal  joint,  ; 
139 
intertaraal,  146 
Pirogofi*'s  method,  120 
of  forearm,  181 
of  leg,  112 

Bier's  method,  117 
by  anterior  long  tegumentary 
periosteal  flap,  with  a  pos- 
terior  short    niusculotegu- 
mentary  flap,  11(5 
by  single  lateral  flap,  117 
by    two    lateral     musculotegu- 

mentary  flaps,  115 
by    two     lateral    tegumentar/ 

flaps  of  equal  size,  114 
circular,  113,  PI.  8 
circular  method,  Figs.  55-58 
flap,  114 

Heine's  method,  116 
supramalleolar,       by       Syme's 

method,  118 
of  penis,  362 


Amputation  of  rectum,  379 
of  toe  through  metatarsal  bone, 

136 
of    toes   in   the    interphalangeal 
joint,  132 
(all)   through   the  metatarsus, 
137 
of  thigh,  154 
by  flaps,  156 
by  Gritty's  method,  161 
by  means  of  circular  incision, 

155 
osteoplastic  supracondylar,  161 
oval,  108 

position  of  operator  in,  87 
position  of  patient  in,  87 
wound,  care  of,  109 
Aneurvsms,  ligation  of  vessels  for, 

58 
Anus,  atresia  of,  operation  for,  384 
operations  upon,  379 
preternatural,  formation  of,  314 
Ankle-joint,  resection  of,  211 
Arched  saw,  42 

Arm,  amputation  of,  184,  PI.  11 
Artery  divided  between  two  liga- 
tures, 61,  Fig.  39 
Arthrectomy,  192 
Arthrotomy,  192 

Atresia  of  anus,  operation  for,  384 
Autoplasty  after  trephining,  221 
Axillary  artery,  ligation  of,  63,  PI. 
2 
location  of,  62 

Bardenheuee's  trap-door  incision 
for  exposing  the  kidney, 
377 

Bassini's  operation  for  inguinal 
hernia,  368 

Bellied  scal]>el,  17 

Bicipital  artery,  ligation  of,  68 

387 


388 


ISDEX. 


Bergmatin's   operation   for    hydro- 
cele, cSdO 
Biers  method  of  amputating  leg, 

117 
Biliarv  apparatus,  operations  upon, 

319 
Billroth's  cannula,  302 
method  of  submental  removal  of 

tongue,  251 
method  of  uranoplasty.  266 
Bladder,  operations  on,  346 
puncture  of,  336 
suture  of,  55 
Blood,  transfusion  of.  69 
Bloodless  approximation  of  wounds. 
44 
methods  of  dividing  tissues,  39 
Bloody  suture,  44 
Blunt  dissection.  33 
Blunt-pointed  knife,  17 
method  of  using,  34 
Bone  brace.  Fig.  37 

division  of.  41 
Bone-forceps,  43 
Bone-shears,  43 
Bones,  division  of.  17 

percutaneous  nailing  of,  53 
suture  of,  52 
Bowel,  resection  of,  315 

suture  of,  53,  PI.  1 
Brachial  artery,  ligation  of,  65,  PI. 

2 
Bramann's   operation  for  exposure 

of  bladder.  350 
Bruns  on  malignant  tumors  as  an 
indication  for  resection  of 
foot,  217 
on  paralytic  club-foot  as  an  indi- 
cation for  resection  of  foot. 
217 
Brauns's     cheiloplastv,    252,    Fig. 
155 
incision  for   resection   of  elbow, 

204 
method    of   tibiocalcaneal   resec- 
tion of  foot.  218 
modification  of  Pirogoff's  ampu- 
tation. 131 
Buccinator  nerve,  extrabuccal   ex- 
posure of.  269 
Biidinger  and  Witzel's  method   of 
implantation  of  ureter,  379 
Biingner,  divulsion  of  vas  deferens, 

358 
Butcher's  saw,  42 


Cannula  for  tracheotomy,  282,  283 
Carotid  artery,  ligation  of,  292 
Caselli  on  shortening  of  leg  after 
luxations  of  hip  as  an  in- 
dication   for    resection   of 
foot,  217 
Castration,  358 
Catheter  coude,  323,  325 

metallic,  introduction  of,  328 

retention.  334 

rigid,  mode  of  introducing,  327 

soft,  mode  of  introducing,  326 
Catheterization,  322 

posterior,  341 
Catheters,  varieties  of,  323,  325 
Cautery.  a<'tual,  39 
Celiotomy,  30S 

mode  of  making  incision  in,  309 
Chain-saw,  42 
Chassaignac's  incision  for  resection 

of  elbow-joint,  199 
Cheek,  plastic  operations  on.  259 
Cheiloplasty.  Bruns's,  252,  Fig.  155 

Dieffenbach's,  252,  Figs.  152,  153 

Langeubeck's,  252,  Fig.  154 
Chisel  and  mallet,  43 
Cholecystectomy.  320 
Cholecystendysis,  320 
Cholecystenterostomy,  321 
Cholecystoduodenostomy,  321 
Cholecystojejunostomy,  321 
Cholecystotomy,  319 
Choledochoduodenostomy,  321 
Choledochotomy.  321 
Choparfs  joint.  149 

operation,  149 
Circular  saw,  43 
Circumcision,  360 
Colostomy,  314.  PI.  19 
Continuity,  ligation  in,  57 
Cricothyrotomy.  275.  276 
Cubital  artery,  ligation  of,  QQ,  PI.  3 
Cutaneous  incisions,  25 

forms  of,  25 
Cystopexy,  349 
Cystotomy,  350 
I      su})rapubic,  347 

for  intravesical  manipulations, 
.349 
}  for  stone,  348 

Czerny's  incision  for  reaching  the 
transverse  fi.ssure  of  the 
liver,  319 

method   of  plastic  operation  on 
cheek,  257 


lyDEX. 


389 


Deep  dissection,  26 
Dieffenbach's      cheiloplastv,      252, 
Figs.  152,  153 
methotl  of  uranoplasty,  266 
Dieulafoy's  aspirator,  303 
Dissection  between  two  forceps,  33, 
Fig.  35 
blunt,  33 
deep,  26 
free,  33 

with  aid  of  grooved  director.  33, 
Fig.  14 
Dittel  on  lateral  prostatectomy,  357 
Division  of  hone,  41 
of  tissues,  17 
bloodless  methods,  39 
by  puncture,  3-':^ 
with  scissors,  34,  Fig.  17 
Dorsalis   pedis   arterj-,  ligation  of, 
85 

ECRASEMENT.  41 

Ecraseur,  41.  Fig.  21 
Elastic  ligature,  41 
Elbow-joint,  resection  of.  199 
Elephantiasis,    ligation    of   vessels 

for,  57 
Eiitero-anastoniosis,  317 
Enterostomy,  313 

Enucleation,  86  I 

at  ellxjw-joint,  182 
at  knee-joint,  153 
of  all  four  fingers  through  meta^ 
carpal  bone,  175  j 

of  foot,  subastragaloid,  150  | 

of  hand  by  circular  incision,  176    i 
by  flap-incisions,  131  ' 

of    thumb    at      carpometacarpal 
joint,  173 
Epilepsy,     ligation      of     vertebral 

artery  for.  oS 
Esmarch's  method  of  exarticulating 
the  humerus.  1S8 
of  exarticulation,  112 
of  femur,  163 
Esophagotomy,  external,  233 
Exarticulatio  pedis  sub  talo,  151 
Exarticulation.  110  . 

at  the  wrist.  175  I 

of  femur  at  hip-joint  by  method 

of  Esmarch,  163 
of     fingers    at     interphalangeal 
joints    and    at    metatarso-  , 
phalangeal  joints,  167 
of  foot,  iutertarsal,  144 


Exarticulation  of  great  toe,  together 
with  metatarsal  bone,  138 
with  formation  of  anterior  and 
posterior  flaps,  163 
of  humeru.s,  1"n5 

by  a  circular  incision  and  with 
longitudinal      incision     by 
I  Esmarch's  method,  188 

I  by  a  deltoid  flap.  Ie6 

of  leg  at  knee-joint,  153 
of  little  finger,  174 
of  little  toe.  together  with  meta- 
tarsal bone,  139 
of  toe  in   interphalangeal  joint, 
132 
Excision  of  prostate,  356 
Exclusion  of  intestine,  317 
Extirpation  of  hip,  167 
of  seminal  vesicles.  356 
of  testicle,  358 
Extremities,  operations  on,  57 
Extubator,  285 

Fabrictts's  method  of   operating 

for  femoral  hernia.  371 
Femoral  artery,  ligation  of,  at  junc- 
tion of  middle  and  upper 
thirds  of  thigh.  75.  PI.  4 
below  Poupart's  ligament.  75, 

PI.  4 
in  adductor  canal,  77,  PI.  5 
location  of,  74 
hernia,  operation  for.  365 
radical  operation  for,  369 
Femur,  exarticulation  of,  163.    See 
Exarticulation. 
osteotomy  of.  221 
Fifth  nerve,  exposure  of  second  and 
third   divisions  by  method 
of  Kronlein,  272 
exposure  of  third  division  at  base 
of  skull,  -273 
Finger,  amputation  of,  174 
Fingers,  exarticulation  of,  167.    See 
Rrarticuhition. 
resection  of,  206 
Fistula,  gastric,  formation  of,  311 
intestinal,  formation  of.  313 
rectal,  operation  for,  3"*2 
urethral,  operation  for,  363 
Fleurant,  trocar  of,  337 
Foot,  amputation  of.     See  Amputa- 
tion. 
resection  of.  214 
subastragaloid  enucleation  o^  150 


390 


INDEX. 


Forearm,  amputation  of,  181 
Fowler  on  appendicitis.  322 
Frank's  method  of  gastrotomy,  313 
Free  dissection,  33 
Frontal  nerve,  exposure  and  extrac- 
tion of,  267 

Gall-bladder,  operations  on,  319 
extirpation  of,  320 
nature  of,  56 

Galvanocaustic  suare,  41 

Galvanocautery,  41 

G^sseriau  gangliou,  extirpation  of, 
by  method  of  Krause,  274 

Grastric  fistula,  formation  of,  311 

Gastroenterostomy,  313 

Gastrostomy,  311.  PL  19 

Genito-urinarv  organs,  operations 
on,  322 

Gersuny's  method  of  plastic  opera- 
tion on  cheek,  259 

Gigli  wire  saw,  228 

Gill  (M.  C.)  on  extirpation  of  en- 
larged middle  lobe  of  pros- 
tate, 357 

Goiter,  operation  for,  299 
resection  of.  301 

Graefe's  incision  for  ligation  of  in- 
nominate artery,  291 

Granny's  knot,  62 

Great  toe,  exarticulation  of.  See 
Exarticulation. 

Gritty's    incision   for   resection   of 
wrist,  206 
operation,  161 

Grooved  director,  dissection  with  aid 
of,  33,  Fig.  14 

Giinther's  modification  of  PirogoflPs 
amputation,  131,  Figs.  76, 
79 
operation,  150 

Gussenbauer's  clamp,  52 

Hahx's    method    of    resection  of 

knee-joint,  211 
Kalsted's  operation  for  removal  of 

breast,  306 
Hand,  enucleation  of.  176 
Harelip,  operations  for,  260 
Heine's  method  of  amputation  of 

leg,  116 
Helfrich's  operation  for  exposure  of 

bladder,  350 
Hemorrhage  after  operation,  control 

of,  109 


Hemorrhoids,  cauterization  of,  383 
excision  of,  384 
operation  for,  383 
removal  by  elastic  ligature,  384 
Hernia,  adherent,  treatment  of,  367 
femoral,  operation  for,  365 
radical  operation  for,  369 
inguinal,  operation  for,  365 
radical  operation  for,  367 
operations  for,  364 
radical  operation  for,  367 
umbilical,    radical  operation  for, 
371 
Herniotome,  34 
Herniotomy,  365 

Heteroplasty  after  trephining,  224 
Hip-joint,  resection  of,  207 
Hueter's   incision  for  resection   of 

elbow,  204 
Humerus,     exarticulation   of,    185. 

See  Exarticulation. 
Hiiter's  tenoplasty,  51 
Hydrocele,  operation  for,  359 

Ileocolostomy,  318 
Iliac  arterv,    external,   ligation    of, 
372 
internal,  ligation  of,  373 
ligation  of,  372 
Incisions  of  the  skin,  25 
Inferior  dental  nerve,  exposure  of, 
270 
exposure    of,    within   dental 
canal,  270 
Infrahyoid  pharyngotomy,  287,  PI. 

15 
Infra-orbital   nerve,   exposure    and 

extraction  of,  268 
Inguinal  hernia,  operation  for,  365 

radical  operation  for,  367 
Injections,  parenchymatous,  39 

subcutaneous,  39 
Innominate  artery,  ligation  of,  291 
Intertarsal  amputation  of  foot,  146 

exarticulation  of  foot,  149 
Intestinal  fistula,  formation  of,  313 
Intestine,  exclusion  of,  317 
Intestines,  operations  on,  311 
Intraglandular  enucleation  of  thy- 
roid gland,  300 
Intubation  of  larynx,  284 

indications  for,  284 
Intubator,  285 

Israel's  method  of  plastic  operation 
on  cheek,  259 


INDEX. 


391 


Ivory  pegs,  union  of  bones  by,  52, 
53 

Jaw,  lower,  rcsoctiou  of,  234 

resection  in  its  continuity,  240 
temporary  resection  of,  239 
upper,  resection  of,  229 
Jejunostoniy,  315 
Joints,  resection  of,  191 

Kidney,  excision  of,  374 
movable,  fixation  of,  376 
operations  on,  374 
Knee-joint,  resection  of,  209 
Knife,    blunt-pointed,    metbod    of 
using,  34 
division  of  tissues  with,  18 
methods  of  using,  18 
varieties  of,  17, 18,  19 
Knots,  62 
Kocher  on  resection  of  bowel,  315, 

316 
Kocher's  angular  incision  for  resec- 
tion of  elbow,  205 
incision  for  enucleation  of  thyroid 
gland,  300 
for  unilateral  strumectomy,  300 
method  of  extirpation  of  tongue, 
251 
of  resection  of  knee-joint,  211 
operation    for    inguinal     hernia, 
369 
Konig's  autoplasty  after  trephining, 
224 
incision  for  resection   of   ankle- 
joint,  213 
method  of   resecting  knee-joint, 

213 
modification  of  Langenbeck's  re- 
section of  hip,  208 
operation  for  saddle-nose,  256 
Krause's  flap  for  exposure  of  Gasse- 
rian  ganglion,  228 
method   of  extirpation  of  Gasse- 

rian  ganglion,  274 
sk  i  n  -g  r af t  i  n  g,  254 
Kronlein's     method    of     exposing 
second  and  third  divisions 
of  fifth  nerve,  272 
Kiister   on   protection    of   thoracic 
nerve  in  removal  of  mam- 
mary gland,  306 

Langenbeck's    cheiloplasty,    252, 
Fig.  154 


Langenbeck's  dorsoradial    incision 
for  resection  of  wrist,  205 
incision,  107 
for  infrahyoid   pharyngotomy, 

289 
for  resection  of  ankle-joint,  211 
for  resection  of  elbow-joint,  199 
for  resection  of  lower-jaw.  240, 
PI.  12 
method  of  excision  of  hip-joint, 
207 
of  resection   of  shoulder -joint, 

193 
of  resection  of  upper  jaw,  233 
Laryngofissure,  275 
Laryngotomy,  275 
Larynx,  extirpation  or  removal  of, 
277 
intubation  of,  284 
oi)ening  of,  275 
Lefort's  modification  of  Pirogoflf's 

amputation,  131,   Fig.  80 
Leg,  amputation  of,  112.  See  Ampu- 
tation of  leg. 
exarticulation  of.    See  Exarticida- 
tion. 
Lembert's  suture,  PI.  1,  Fig.  1,  b 
Ligation,  cutaneous  incision  for,  58 
in  continuity,  indications  for,  57 

method  of,  58 
in  upper  extremity,  62 
location  and  identification  of  ar- 
tery in,  59 
of  axillary  artery,  83,  PI.  2 
of  bicipital  artery,  68 
of  brachial  artery,  65,  PI.  2 
of  carotid  artery,  292 
of  cubital  artery,  66,  PI.  3 
of  dorsal  is  pedis  artery,  85 
of  femoral  artery  at  junction  of 
middle  and  upper  thirds  of 
thigh,  75 
below  Poupart's  ligament,  75, 

PI.  4 
cutaneous  incision  for,  Fig.  49 
in  adductor  canal,  77,  PI.  5 
of  iliac  artery,  372 
of  innominate  artery,  291 
of  internal  mammary  artery,  304 
of   internal    saphenous   vein  for 

varicose  veins,  77 
of  lingual  artery,  295,  PI.  17 
of  popliteal  artery,  77,  PI.  6 

cutaneous  incision  for.  Fig. 
51 


392 


INDEX. 


Ligation  of  radial  and  ulnar  arte- 
ries, 70.  PI.  3 
of  subclavian  artery,  295 
above  the  clavicle,  297 
beloNV  the  clavicle,  298 
of  thyroid  artery,  294 

inferior,  299 
of  tibial  arteries,  80,  PI.  7 
of  vessels  in  continuity,  57 
Ligature,  elastic,  41 

ku3t,  method  of  tieing,  61 
Lingual  arterv,  ligation  of,  295,  PI. 
17 
nerve,  exposure  of,  271 
Lisfranc's  articular  line,  140,  141 

operation,  139 
Lister's  dorso-ulnar  incision  for  re- 
section of  wrist,  206 
lead-plate  suture,  49 
Litholapaxy,  345 
Little   toe,  exarticulation   of.     See 

Exarticidation. 
Liicke's   and  Schede's  incision  for 
resection  of  hip,  209 

Macewen  on   supracondylar  oste- 
otomy of  femur,  221 
Malgaigne's  incision  for   resection 

of  upper  jaw,  232 
infrahyoid  pharyngotomy,  287 
operation,  151 
for  harelip,  260 
Mammarv  arterv,  internal,  ligation 

of,  304 
gland,  removal  of,  304 
Maydl  on  uretero-enterostomy  for 

ectopy  of  bladder,  378 
McBurney's   incision  for  resection 

of    vermiform     appendix. 

321 
Mental  nerve,  exposure  of,  271 
Mikulicz's     method     of    exposing 

third     division     of     fifth 

nerve,  273 
Mirault-Langenbeck's  operation  for 

harelip,  260 
Mohrenheim's  triangle,  298 
Monro,    point    of,    for    abdominal 

puncture,  307 
Moreau's  incision  for  resection  of 

elbow,  204 
Murphy's  anastomotic  button,  316 
Muscles,  divided,  suture  of,  49 
of  leg,  anterior,  arrangement  of, 

81 


Muscles  of  popliteal  space  and  calf, 

Fig.  50 
of    thigh,   arrangement    of,    Fig. 

47 
of  upper  extremity,  arrangement 

of,  Fig.  44 

Nails  for  uniting  severed  bones,  52, 

53 
Xeedles,  varieties  of,  Fig.  29 
Xelaton's  operation  for  harelip,  260 
Nephrectomy,  374 
Nephropexy,  376 
Nephrorrhaphy,  376 
Nephrotomy,  374 
Nerve-suture,  51 
Nerves,  extraction  of,  267 

operations  on,  266 
Neurectomy,  267 
Neurexairesis,  267 
Neuroplasty,  51 
Neurotomy,  266 
Niehans's  operation  for  exposure  of 

bladder,  350 
I  Nose,  plastic  restoration  of,  254 

O'Dwyek's  outfit  for  intubation  of 
I  larynx,  264,  285 

I  Ollier's  bayonet-incision  for  resec- 
I  tion  of  elbow,  204 

Omphalectomy,  372 
Omphalocele,   incarcerated,    opera- 
tion for.  371 
Osseous  arthrectomy,  192 
Osteoclasis,  44 
Osteoclasts,  44 
Osteotomia  colli  femoris,  221 

intertrochanterica,  221 
Osteotomy,  218 
of  femur.  221 
of  tibia,  221 
supracondylar,  of  femur,  221 

Palate,   hard,    plastic    operations 
on,  266 
soft,  plastic  operations  on,  265 
Paquelin,    thermo-cautery    of,    41, 

Fig.  19 
Paracentesis  abdominalis,  307 

thoracis,  302 
!  Paraneural  suture,  51 
Paratendinous  suture,  50 
Paravicini's    method    of   exposing 
inferior  dental  nerve,  270 
;  Parenchymatous  injections,  39 


INDEX. 


393 


Park's  incision  for  resection  of  el- 
bow-joint, 199 

Penis,  ampututioii  of,  3()2 

PtTc-iitaneous  nailing  of  bones,  53 

PiTicecal  abscesses,  opening  of,  321 

PiTimural  suture,  ")! 

Pharyngotoniy,  287 
infrahyoid.  2S7,  PI.  15 

Phimosis,  operation  for,  3(50 

Plilebotomy,  GO,  Fig.  4() 

Pirogoff 's  amjJUtatioM  of  foot,  120 

Plastic  operations,  252 

Point  of  Monro,  307 

PoUoson's  method  >f  exarticulating 
leg  at  knee-joint,  154 

Poncet's  operation  of  urethrostomy, 
345 

Popliteal  artery,  ligation  of,  77,  PI. 
6 

Preternatural   anus,  formation   of, 
314 

Primary  suture,  44 

Prostate,  excision  of,  356 

Prostate    gland,    operation    upon, 
355 

Prostatectomy,  3.56 
lateral,  357 

Prostatotomy,  355 

Puncture,  exploratory,  38 
mode  of  performing,  38 
of  abdomen,  .307 
of  bladder,  336 

Racket  incision,  112 
Radial  artery,  ligation  of,  70,  PI.  3 
Reamputation,  indications  for,  86 
Rectal  fistula,  operations  for,  382 
Rectum,  operations  upon,  379 
resection  of,  380 
sacral  exposure  of,  381 
Reef  knot.  Fig.  40 
Regnoli's  method  of  submental  re- 
moval of  tongue,  251 
Resection  knives,  18 

knife,  mode  of  using,  18,  Fig.  11 
of  ankle-joint,  211 

by  Konig's  incision,  213 

bv     Langenbeck's     incision, 

211 
bv  Reverdin-Kocher  method, 
214 
of  bowel,  315 
of  elbow-joint  through  a  dorsal 

longitudinal  incision,  199 
of  fingers,  206 


Resection    of   foot   by   method  of 
Wladimiroff'  and  Mikulicz, 
214 
of  goiter.  301 
of  hip-joint,  207 
of  joints,  indications  for,  192 

of  the  extremities,  191 
of  knee  joint,  209 
of  lower  jaw,  234 

in  its  continuity,  240 
temporary,  239 
of  rectum,  380 
of  shoulder-joint  by  method  of 

Langenbeck,  193 
of  skull,  227 
of  upper  jaw,  229 
of  vas  deferens,  357 
of  vermiform  appendix,  321 
of  wrist-joint,  205 
subperiosteal,  191 
Retention-catheter,  334 
Retractors,    use    of,   in   dissection, 

26 
Reunion  of  tissues,  44 
Reverdin-Kocher     method    of    re- 
section of  ankle-joint,  214 
Rhinoplasty,  254 

Rorer's  incision  for  resection  of  hip- 
joint,  209 
Rydygier  on  shortening  of  leg  after 
resection  of  kuee  as  an  in- 
dication for  resection  of 
foot,  217 

Saddle-xose,  operation  for,  256 

Sailor's  knot,  62 

Salzer  on  danger  of  excluded  por- 
tion of  bowel  in  exclusion, 
318 

Salzer's  method  of  exposing  third 
division  of  fifth  nerve,  273 

Sartorius  muscle,  course  of,  48 

Saw,  Butcher's  arched,  42 
chain,  42 
circular,  43 
wire,  43 

Scalpel,  bellied,  17 

Scissors,  division  with.  34,  Fig.  17 

Scoutetten's  method  of  oral  ampu- 
tation, 108 

Secondary'  suture,  44 

Sedillot's  incision  for  resection  of 
lower  jaw,  240 

Seminal  vesicles,  356 
j  Sharp-pointed  knife,  17 


394 


INDEX. 


Shoulder-joint,    resection    of,    193. 

See  Resection. 
Skin,  circular  iucisiou  of,  25 

division  of,  from  within  outward, 
25 

method  of  holding  knife  in,  18 
Skin-grafting,  54 

Skull,  temporary  resection  of,  227 
Snare,  galvauocaustic,  41 

wire,  41,  Fig.  20 
Soft  parts,  division  of,  17 
Sonneuburg's   method  of   exposing 

inferior  dental  nerve,  270 
Ssabanajefi"s  operation,  162 
Staphylorrhaphy.  265 
Steiner  on  localization  of  branches 
of       middle        meningeal 
artery,  228 
Stirrup  incision,  113 
Stomach,  operations  on.  .311 
Stone,  lateral  incision  for.  344 

median  section  for.  344 
Strumectomy,  unilateral,  300 
Subastrasaloid  enucleation  of  foot, 

150 

Subclavian  artery,  ligation  of,  295 

above  the  clavicle.  297 

below  the  clavicle,  29S 

Subcutaneous  injections,  method  of 

making.  39 
Subperiosteal  resection,  191 
Supracoudvlar  shortening  of  femur. 

221 
Suprapubic  cystotomy,  347 
Surgical  knot,  62 
Suture,  bloody,  44 

continuous,  49.  Fig.  26 

deep.  49 

gauze-pad.  49,  Fig.  30 

glover's,  49 

interrupted.  49.  Fig.  25 

Lister's  lead-plate,  49 

mattress.  49 

of  bladder.  55 

of  bones,  52 

of  bowel.  53.  PI.  1. 

of  divided  muscles,  49 

of  gall-bladder,  56 

of  nerves.  51 

of  patella  with  wire.  Fig.  36. 

of  tendons.  49 

paraneural.  51 

paratendinous,  50 

perineural.  51 

primary,  44 


Suture,  secondary,  44 

simple  knotted,  44,  Fig.  25 
introduction  of,  45,  Fig.  31 
Syme's  method   of  supramalleolar 

amputation,  118 
Synovial  arthrectomy,  192 
Szymanowsky's  incision  for  resec- 
tion of  elbow,  204 

Tampon-canxula  in  tracheotomy, 

283 
Tenacula,  use  of,  in  surgical  dissec- 
tion, 26 
Tendons,  suture  of,  49 
Tenoplasty,  51 
Tenotome,  mode  of  using,  18,  Figs. 

12,13 
Tenotomes,  18 
Testicle,  extirpation  of,  358 
Thermocauterv    of    Paquelin,    41, 

Fig.  19 
Thiersch's  extraction  of  nerves,  267 

skin-grafting,  254 
Thigh,  amputation  of,  254.   See  Am- 

pidntion. 
Thoracotomy.  303 
Thorax,  paracentesis  of,  .302 
Thumb,  enucleation  of,  173 
Thvroid  arterv,  inferior,  ligation  of, 
299 
superior,  ligation  of  294 
gland,     intraslandular    enuclea- 
tion. 300 
Thyrotomy,  275 
Tibia,  osteotomy  of,  221 
Tibial  arteries,   ligation  of,  80,  PI. 

7 
Tissues,  division  of,  17 
by  puncture,  38 
reunion  of,  44 
Toes,  amputation  of.     See  Amputa- 
tion of  toes. 
exarticulation     of,    in    iuterpha- 
langeal  joint,  132 
Tongue,  operations  on,  243 

submental  removal  of,  251 
Tracheal  cannula,  283 
Traclieotomy.  278 
indications  for.  278 
inferior.  280,  PI.  14 
superior,  279 
Transfixion.  107 
Transfusion  of  blood.  69 
Trendelenburg's     tampon-cannula, 
283 


INDEX. 


395 


Trephiiiinp,  22.'i 

iiidiratidiis  fur,  2*23 
TrigfiuiiKil    UL-uralgia,  ligation  of 

carotid  artery  lor,  .">« 
Trigeminus,  operations  ou,  274 
Trocar,  niotlc  ol"  using,  3d 
Trzetizky  on   injury   of  vessels  in 

abdomiual  puncture.  307 
Tumors  of  tongue,  excision  of,  243 

Ulnar    artery,    ligation  of,  70, 

PI.  3 
Umbilical  hernia,  radical  operation 

for,  371 
Unilateral  strumectomy,  300 
Uranoplasty,  2G() 
Ureter,  inflammation  of,  379 

operations  on.  377 
Uretero-enterostomy,  378 
Ureterolithotomy,  .377 
Ureteroneocystostomy,  378 
Urethral     fistula,     operation    for. 

Urethrostomy,  .34.5 
Urethrotomy,  external,  337 

indications  for,  342 

internal,  343 

with  a  guide,  340 

without  a  guide,  340 

Van*  Hook's  invagination  suture, 

379 
Vas  deferens,  divulsion  of,  358 

extirpation  of,  358 

resection  and  extirpation  of,  357 


Velpeau's  incision  for  resection  of 

upper  jaw,  232 
method  of  resection  of  hip-joint, 

207 
Venous  infusion  of  saline  solution, 

69 
Vermiform  appendix,  321 
VerneuiTs  operation,  164 
Vogt's    incision     for    resection    of 

elbow,  204 
Volkmann's  method  of  resection  of 

knee-joint,  211 
operation  for  hydrocele,  360 
Von  Walther  on  reimplantation  of 

bone  after  trephining,  224 

Walther's    method    of    exarticu- 

lating  little  finger,  174 
Weber  on  cutaneous  incision  for  re- 
section of  upper  jaw,  2.30 
Wire  loop  for  division  of  tissues, 
46,  Fig.  20 
saw,  43 
Witzel's  method  of  cystostomy,  313 
Wladimirofl"  and   Mikulicz  method 

of  resection  of  foot,  214 
Wolff's  method  of  uranoplasty,  266 
Wolfler,  incomplete  exclusion  of  the 

bowel,  317 
Wolfler's  gauze-pad  suture,  49 
Wrist-joint,  resection  of,  205 

Zuckerkandl's  operation  for  ex- 
posure of  buccinator  nerve, 
269 


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AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  II.  IIowkll,  Ph.D.,  M.  D.,  rrofessor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
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■Mie  volume  the  entire  subject  of  Human  Physiulogj'  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
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particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
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upon  a  compreliensive  knowledge  of  the  subject  assigned  to  him;  another,  and 
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obtained  by  following  courses  of  instruction  under  different  teachers.  The 
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student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

The  main  divisions  of  the  subject-matter  are  as  follows  :  General  Physiology 
of  Muscle  and  Nerve  —  Secretion  —  Chemistry  of  Digestion  and  Nutrition — 
Movements  of  the  Alimentary  Canal,  Bladder,  and  Ureter — Blood  and  Lymph 
— Circulation — Respiration — Animal  Heat — Central  Nervous  System — Special 
Senses  —  Special  Muscular  Mechanisms  —  Reproduction  —  Chemistry  of  the 
Animal  Body. 

C'OXTRIBl  TORS  : 

HENRY  P.  BOWDITCH.  M.  D.,  WARREN  P.  LOMBARD,  M.D., 

Professor  of  Physiology,  Harvard  Medi-  Professor   of  Physiology,  University  of 

cal  School.  I  Michigan. 

JOHN  G.  CURTIS,  M.  D  |  GRAHAM  LUSK,  Ph.  D.. 

Professor  of  Physiology,  Columbia  Uni-  Prnfe<;sor   nf   P  .v<;inlr,P^     Ynle    MeHiral 

versity,  N.  Y.  (College  of  Physicians  Professor  ot    1  li>siology,    \ale   Medica/ 

and  Surgeons).  I  °° 

IISNRY  H.  DONALDSON,  Ph.D.,  W.  T.  PORTER,  M.D., 

Hcad-Pr'.fc>>or    of    Neurology,    Univer-  Assistant  Professor  of  Physiology,  Har- 

sity  of  (,'hicago.  vard  Medical  School. 

W.  H.  HOWELL,  Ph.D.,  M.  D.,  EDWARD  T.  REICHERT,   M.D.. 

Professor  of  Physiology,  Johns  Hopkins  ,  Professor  of  Physiology,  University   of 

University.  I  Pennsylvania. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Profes.sor  of  Physiology,  Cohim-     HENRY   SEWALL,  Ph.D.,   M.  D.. 

bia   University,    N.    Y.    (College    of  1  Profe.ssorof  Physiology,  Medical  Depart 

Physicians  and  Surgeons).  I  ment,  University  of  Denver. 


IV.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  ^7.00  net;  Sheep  or 
Half- Morocco,  $8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

COXTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Baltimore.  Md. 
Sanger  Brown,  Chicago,  111. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney.  Charlottesville,  Va. 
John  Chalmers  Da'Costa,  Philada.,  Pa. 
I.  N.  Uanforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia.  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.   Edes,  Jamaica  Plain,  Mass. 
Augustus  A.  Eshner,  Philadelphia.  Pa. 
J.  T.  Eskridge,  Denver,  Col. 
F.  Forchheimer,  Cincinna'^i,  O. 
Carl  Frese.  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras.  Philadelphia.  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book— Applied  Therapeutics— to  ^indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

While  the  scientific  superiority  and  the  practical  desirability  of  the  metric 
system  of  weights  and  measures  is  admitted,  it  has  not  been  deemed  best  to 
discard  entirely  the  older  system  of  figures,  so  that  both  sets  have  been  given 
where  occasion  demanded. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell.  Philadelphia,  Pa. 
W.  P.  Northrup.  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare.  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal.  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaiighan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


CATALOGUE    OF  MEDICAL    WORKS.  5 

For  Sale  by  Subscription. 

AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
One  handsome  octavo  volume  of  over  looo  pages,  with  nearly  900  colored 
and  half-tone  illustrations.  Prices:  Cloth,  ^7.00;  Sheep  or  Half-Morocco, 
$8.00. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
Books  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparation  of  the  "American  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  wTiters  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  modern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


COXTRIBUTORS : 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickin.';on. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garnsues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz. :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  tiiem.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — Nei.u  York  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Alex.  J.  C.  SKE>fE. 


W.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal- octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  $5.ck)  net;  Sheep  or  Half-Morocco,  $6.00  net. 

VOI.IJME  I.   CONTAINS: 

Hygiene. — Fevers  (Ephemeral,  Simple  Con-  mycosis.  Glanders,  and  Tetanus. — Tubercu- 
tinued,  Typhus,  Typhoid,  Epidemic  Cerebro-  \  losis.  Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
spinal  Meningitis,  and  Relapsing). — Scarla-  i  las.  Malaria.  Cholera,  and  Yellow  Fever. — 
tina,  Measles,  Rotheln,  Variola,  Varioloid,  '  Nervous,  Muscular,  and  Mental  Diseases  etc. 
V  iccinia, Varicella,  -Mumps, Whooping-cough,  1 
Anthrax,  Hydrophobia,  Trichinosis,  Acrino-  | 

VOL.1  ME   II.  CONTAINS: 


Urine  (Chemistry  and  Microscopy). — Kid- 
ney and  Lungs.— Air-passages  (Larynx  and 
Bronchi)  and  Pleura.— Pharynx,  (Esophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


— Peritoneum,  Liver, and  Pancreas. — Diathet- 
ic Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithaemia,  and  Diabetes.) — 
Blood  and  Spleen. — Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBLTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz.  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 

W.  Gil  man  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
".nd  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  ts,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  iilustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — Nerv  York  Medical  yournal. 

"  A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"  \  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  yournal. 


CATALOGUE    OF  MEDICAL    WORKS. 
» — 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam \V.  Klen,  M.D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.  D. 
Forming  one  handsome  royal-octavo  volume  of  1250  pages  (10x7  inches), 
with  500  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Prices  :  Cloth',  $7.00  net;  Sheep  or  Half- Morocco,  ^8.00  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED, 

With  a  Section  devoted  to  "The  Use  of  the  Rbntgen  Rays  in  Surgery." 

The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
same  time  be  recommended  to  the  medical  student  has  been  deeply  felt,  espe- 
cially by  teachers  of  surgery;  hence,  when  it  was  suggested  to  a  number  of 
these  that  it  would  be  well  to  unite  in  preparing  a  text-book  of  this  description, 
great  unanimity  of  opinion  was  found  to  exist,  and  the  gentlemen  below  named 
gladly  consented  to  join  in  its  production.  While  there  is  no  distinctive  Amer- 
ican Surgery,  yet  America  has  contributed  very  largely  to  the  progress  of  modern 
surgery,  and  among  the  foremost  of  those  who  have  aided  in  developing  this  art 
and  science  will  be  found  the  authors  of  the  present  volume.  All  of  them  are 
teachers  of  surgery  in  leading  medical  schools  and  hospitals  in  the  United  States 
and  Canada. 

Especial  prominence  has  been  given  to  Surgical  Bacteriology,  a  feature  which 
is  believed  to  be  unique  in  a  surgical  text-book  in  the  English  language.  Asep- 
sis and  Antisepsis  have  received  particular  attention.  The  text  is  brought  well 
up  to  date  in  such  important  branches  as  cerebral,  spinal,  intestinal,  and  pelvic 
surgery,  the  most  important  and  newest  operations  in  these  departments  being 
described  and  illustrated. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  orip:inal  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens. 

CONTRIBrXORS : 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  VV.  Keen,  Philadelphia. 
Charles  B   Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  N.  Y. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  ('hicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thom.son,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice."— 
London  Lancet. 


Py.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  Baldy,  M.  D.     Forming  a  handsome  royal-octavo  volume, 

with  341  illustrations  in  text  and  38  colored  and  half-tone  plates.     Prices  : 
Cloth,  36.00  net;  Sheep  or  Half-Morocco,  $7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 


COXTRIB1JTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
).  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most 
complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yournal. 

"  A  valuable  addition  to  the  literature  of  Gynecology.  The  writers  are  progressive, 
aggressive,  and  earnest  in  their  convictions." — Medical  News,  Philadelphia. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in 
struction." — Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  0/  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  yournal  0/  Medical  Sciences. 


CATALOGUE   OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  TiiOMi'soN  S.  Westcott,  M.  D.  In  one  handsome  royaI-8vo 
volume  of  1250  pages,  profusely  illustrated  with  wood-cuts,  halftone  and 
colored  plates.    Net  Prices:  Cloth,  ^7.00;  Sheep  or  Half-Morocco,  38.00. 

SECOND  EDITION,   REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  podiatrists,  representing  collectively  the  teachmgs  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  TKAcriCAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulse  and  therapeutic  procedures. 
Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin  ;  while  the  introductory  chapters  cover  fully  the 
important  subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of 
Food.  Tracheotomy,  Intubation,  Circumcision,  and  such  minor  surgical  pro- 
cedures coming  within  the  province  of  the  medical  practitioner  are  carefully 
Considered. 

CONTRIBUTORS : 

Dr.  I'homas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York, 
Henry  AL  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K    Mills,  Philadelphia. 
James  E.  Moore,  Minneapolis. 
F    Gordon  Morrill,  Boston. 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  l)Ovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  AL  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
VV.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCos^a,  Philadelphia. 
1.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henr^'  Koplik.  New  York. 


John  H.  Miisser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  A    Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  M.  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
AL  Allen  Starr,  New  York. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
vV.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich 
Thompson  S.  Westcott,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 
J.  William  White.  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


lO  JV.   B.   SAUNDERS' 


A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Pediatric  Society;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc. ;  and  Henry  Hamilton,  author 
of  "  A  New  Translation  of  Virgil's  ^neid  into  English  Rhyme ;"  co- 
author of  "Saunders'  Medical  Lexicon,"  etc.;  with  the  Collaboration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  ver}'  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices  :  Cloth,  ;$5.oo  net ; 
Sheep  or  Half-Morocco,  ^6.00  net;  with  Denison's  Patent  Ready- Refer- 
ence Index ;  without  patent  index,  Cloth,  $4.00  net ;  Sheep  or  Half- 
Morocco,  35.00  net. 

PROFESSIOXAI.   OPINIONS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henry  M.  Lyman,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.   A.   LiNDSLEY.  M.   D., 

Professor  of  Theory  and  Practice  of  Medici7ie,  Medical  Dept.  Yale  University : 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn, 


AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surger)- 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes^ 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.     Price  per  Volume,  ^2.50  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full   and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe  ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


CATALOGUE   OF  MEDICAL    WORKS.  II 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  \\  Akki.N,  M.  D.,  LL.D.,  I'rofosor  of  Surger)-,  Medical  Depart- 
ment Harvard  University;  Surgeon  to  the  Massachusetts  General  Hospital, 
etc.  A  handsome  octavo  volume  of  832  pages,  with  136  relief  and  litho- 
graphic illustrations,  t^i  of  which  are  printed  in  colors,  and  all  of  which 
were  drawn  by  William  J.  Kaula  from  original  specimens.  Prices :  Cloth, 
$6.00  net ;   Half- Morocco,  37.00  net. 

"The  volume  is  for  the  bedsfde,  the  amphitheatre,  and  the  ward.  It  deals 
with  things  not  as  we  see  them  through  the  microscope  alone,  but  as  the  prac- 
titioner sees  their  effect  in  his  patients;  not  only  as  they  appear  in  and  affect 
culture-media,  but  also  as  they  influence  the  human  body ;  and,  following  up 
the  demonstrations  of  the  nature  of  diseases,  the  author  [x>ints  out  their  logical 
treatment."  {^Xew  York  Medical  yotimal).  "  It  is  the  handsomest  specimen 
of  book-making  *  *  *  that  has  ever  been  issued  from  the  American  medical 
press  "   {^American   Journal  of  the  Medical  Sciences,   Philadelphia), 

Without  Exception,  the  Illustrations   are  the  Best  ever   Seen  in  a 

"Work  of  this  Kind. 


"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  tlie  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section.  " — Annals  of  Surgery,  Philadelphia. 


PATHOLOGY  AND  SURGICAL  TREATMENT  OF  TUMORS, 
By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgen,-,  Rush  Medical  College ;  Professor  of  Surgen.',  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Prices:  Cloth,  $6.00  net; 
Half-Morocco,  37.00  net. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  te.xt-books  and 
systems  of  surgen.-  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  busy  practitioner,  and  a  reliable,  safe  guide  for  the 
surgeon.  The  more  difficult  operations  are  fully  described  and  illustrated.  More 
than  one  hundred  of  the  illustrations  are  original,  while  the  remainder  were 
selected  from  books  and  medical  journals  not  readily  accessible. 

"The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — yournal  0/ Anterican  Medical  A r so- 
ciation,  Chicago. 


12  tV.  B.   SAUNDERS' 

MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  fine  wood-cuts  in  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  $4.00  net;  Sheep  or  Half-Morocco,  $5.00  net. 

FOURTH  AMERICAN  EDITION,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and 
Italian.  The  issue  of  a  third  American  edition  within  two  years  indicates  the 
favor  with  which  it  has  been  received  by  the  profession. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  $3.00  per  Part.     Parts  I  to  8  now  ready. 

"The  plates  are  beautifully  executed."— Jonathan  Hutchinson,  M.  D.  (London 
Hospital). 

"  The  plates  in  this  Atlas  are  remarkably  accurate  and  artistic  reproductions  of  typical^ 
examples  of  skin  disease.  The  work  will  be  of  great  value  to  the  practitioner  and  student." 
— William  Anderson,  M.  D.  (St.  Thomas  Hospital). 

"  If  the  succeeding  parts  of  this  Atlas  are  to  be  similar  to  Part  i,  now  before  us,  we  have 
no  hesitation  in  cordially  recommending  it  to  the  favorable  notice  of  our  readers  as  one  of 
the  finest  dermatological  atlases  with  which  we  are  s.cqvL^xnx.eA."'— Glasgow  Medical  yournal, 
Aug.,  1895. 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner." — American  Medico-Surgical  Bulletin,  Ffeb.  22,  1896. 

"The  introduction  of  explanator>'  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say.  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — Neiv  York  Medical  Journal,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
by  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it."— Medical  Record,  N.  Y.,  Feb.  i, 


CATALOGUE    OF  MEDICAL    WORKS.  1 3 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A,  M,  Stoney,  Graduate  of  the  Training-School 
for  Nurses,  Lawrence,  Mass.;  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
plates.     Cloth.     Price,  ^^1.75  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  of  private  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fire- 
quently  extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse  :  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room:  its  selection,  preparation,  and  management. 

III.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 

cologic cases. 

IV,  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 

VI.  Nursing  of  the  New-born  and  Sick  Children, 
VII.   Physiology  and  Descriptive  Anatomy. 

The  Appendix  contains  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick ;  Recipes  for 
Invalid  Foods  and  Beverages  ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Later;  List  of  Abbreviations ;  Dose-List;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  ever^-thing  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
ll'owen  and  Children,  Aug.,  1896. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiolog>-  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Haemaiozoa,  and  Psorosperms,  By  Edgar  M,  Crookshank,  M.  B.,  Pro- 
fessor of  Comparative  Pathology  and  Bacteriolog)',  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price,  36.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Profe^^sor  Crookshank's 
"  Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Ofticers  of 
Health,  and  for  Veterinary  Inspectors. 


14  IV.   B.   SAUNDERS' 


A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL.    For  the  Use  of  Students.     By  Arthur  Clarkson,  M.  B., 

C.  M.,  Edin.,  formerly  Demonstrator  of  Physiolog}-  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
$6.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tol<^,  in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  gereral 
methods  of  Histolc^' ;  subsequent!}-,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systemaiically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
m^hods  of  jH-ej3aration. 

"We  would  most  cordialij^  recommend  it  to  all  students  of  histology." — Dublin  Medical 
yourna-l. 

"It  is  pleasaot  lo  give  unqualified  praise  to  the  colored  illustrations  ;  .  .  .  the  standard  is 
hjg^.  and  many  of  them  are  not  only  extremely  beautiful,  but  verj'  clear  and  demonstra- 
tive. .  .  .  The  plan  of  the  book  is  excellent." — Liverpool  Medical  Journal. 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  Sydney  Rowland, 
B.  A.,  C::;..  .  A  series  of  collot\-pe  illustrations,  with  descrij-'tive  text, 
-••--t--'-        -  -"cations  of  the  New  Photography  to  Medicine  and  Sur- 

:,  $1.00.      Parts  I.  to  V.  now  ready. 

li^e  -i/.^jci-  ■  -  •  „Llication  is  to  put  on  record  in  permanent  form  some  of 
the  most  str  .ications  of  the  new^  photography  to  the  needs  of  Medicine 

and  Suigen. 

The  pit^ress  of  this  new  art  has  been  so  rapid  that,  although  Prof.  Rontgen's 
discovery  i=  r'  '  :  of  vesterday,  it  has  already  taken  its  place  among  the 
approved  ar  1  is  to  diagnosis. 

WATER  AND  WATER  SUPPLIES.  By  John  C.  Thresh,  D.  Sc, 
M.  B.,  D.  P.  H.,  Lecturer  on  Public  Health,  King's  College,  London; 
Editor  of  the  "Journal  of  State  Medicine,"  etc.  i2mo,  438  pages,  illus- 
trated. Handsomely  bound  in  Cloth,  with  gold  side  and  back  stamps. 
Price,  $2.25  net. 

This  work  will  fiiTOish  any  one  interested  in  public  health  the  information 
requisite  for  forming  an  opinion  as  to  whether  any  supply  or  proposed  supply 
is  sufficiently  wholesome  and  abundant,  and  whether  the  cost  can  be  considered 
reasonable. 

The  WM-k  does  not  pretend  to  be  a  treatise  on  Engineering,  yet  it  contams 
sufficient  detail  to  enable  any  one  who  has  studied  it  to  consider  intelligently  any 
schem«  which  may  be  submitted  for  supplying  a  community  with  water. 


CATALOGUE    OF  MEDICAL    WORKS.  15 


DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  c;.  K.  i)K  ScHWKiN'irz,  M.  D.,  Professor  of  Ophtlialiuology  in 
the  JelTcrson  Medical  College,  I'liiladelphia,  etc.  A  handsome  royal- 
octavo  volume  of  679  pages,  with  256  fine  illastrations,  many  of  which  are 
original,  and  2  chromo-lilhographic  plates.  Prices :  Cloth,  $4.00  net ; 
Sheep  or  Half-Morocco,  $^.00  net. 

The  object  of  this  work  is  to  present  to  the  student,  and  to  the  practitioner 
who  is  beginning  work  in  the  fields  of  ophthalmology,  a  plain  description  of  the 
optical  defects  and  diseases  of  the  eye.  To  this  end  special  attention  has  been 
paid  to  the  clinical  .<iide  of  the  question  ;  and  the  method  of  examination,  the 
symptomatology  leading  to  a  diagnosis,  and  the  treatment  of  the  various  ocular 
defects  have  been  brought  into  prominence. 

THIRD  EDITION,   THOROUGHLY  REVISED. 

The  entire  book  has  been  thoroughly  revised.  In  addition  to  this  general 
revision,  special  paragraphs  on  the  following  new  matter  have  been  introduced  : 
Filamentous  Keratitis,  Blood-staining  of  the  Cornea,  Essential  Phthisis  Bulbi, 
Foreign  Bodies  in  the  Lens,  Circinate  Retinitis,  Synmietrical  Changes  at  the 
Macula  Lutea  in  Infancy,  Hyaline  Bodies  in  the  Papilla,  Monocular  Diplopia, 
Subconjunctival  Injections  of  Germicides,  Infiltration-Anaesthesia,  and  Steriliza- 
tion of  Collyria.  Brief  mention  of  Ophthalmia  Nodosa,  Electric  Ophthalmia, 
and  Angioid  Streaks  in  the  Retina  also  finds  place.  An  Appendix  has  been 
added,  containing  a  full  description  of  the  method  of  determining  the  corneal 
astigmatism  with  the  ophthalmometer  of  Javal  and  Schiotz,  and  the  rotations 
of  the  eyes  with  the  tropometer  of  Stevens.  The  chapter  on  Operations  has 
been  enlarged  and  rewritten. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  yournal. 

"  The  work  is  characterized  by  a  lucidity  of  expression  which  leaves  the  reader  in  no 
doubt  as  to  the  meaning  of  the  language  employed.  .  .  .  We  know  of  no  work  in  which 
these  diseases  are  dealt  with  more  satisfactorily,  and  indications  for  treatment  more  clearly 
given,  and  in  harmony  with  the  practice  of  the  most  advanced  ophthalmologists." — Mari- 
time Medical  Neivs. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology',  it  is  the  best  single  volume  at  present  published." — Medical  Ne-ws. 

"  The  latest  and  one  of  the  best  books  on  Ophthalmology.  The  book  is  thoroughly  up  to 
date,  and  is  certainlj'  a  work  which  not  only  commends  itself  to  the  student,  but  is  a  ready 
reference  for  the  busy  practitioner." — International  Medical  Review. 

PROFESSIONAL.  OPINIONS. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D. 
Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 

in  the  University  of  Pennsylvania. 

"Contains  in  concise  and  reliable  form  the  accepted  views  of  Ophthalmic  Science." 

William  Thomson,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia,  Pa. 


1 6  TF.   B.   SAUNDERS' 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  Joseph  McFari_a_nd, 
M.  D.,  Professor  of  Patholog}-  and  Bacterioiogy  in  the  Medico-Chirurgical 
Collie  of  Philadelphia,  etc.  497  pages,  finely  illustrated.  Price,  Qoth, 
S2.50  r.cr. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory- traimng  in  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  staining.-, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  aflbrd 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modem  science  shows  to  go  far  in  explaining  the  etiology  of  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 

useful  to  those  for  whom  it  is  written. — Londcn  Lancet,  Aug.  29,  1S96. 

"  The  author  has  succeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  siunmarj-  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  \*-ide  circulation  among  English-speaking 
students  of  medicine." — .V.  Y.  Medical  Journal,  April  4,  1896. 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch   of  medical 

science." — Edinburgh  Medical  ycurnal,  July,  1896. 

LABORATORY  GUIDE  FOR  THE  BACTERIOLOGIST.  By 
L.\XGDON  Frothixgham,  M.  D.  v..  Assistant  in  Bacteriolog}-  and  Veteri- 
nary Science,  Sheffield  Scientific  School,  Vale  University.  Illustrated. 
Price,  Cloth,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work 

"  It  is  a  convenient  and  usefiil  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  woiild  otherwise  be  consumed  in  looking  up  the 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Armrican  Med.- 

Su  rg.  Bull-: t in . 

FEEDING  IN  EARLY  INFANCY.  By  Arthur  V.  Meigs,  M.  D. 
Bound  in  limp  cloth,  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Prop^ortion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Conden.^d  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  *' Pasteurization  "  of 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants.  y*/" 


CATALOGUE    OF  MEDICAL    WORKS.  \J 


ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection  "  By  Charles 
B.  Nancrp:I)K.,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition,  lost  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ^2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy. 


"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in 
their  work  in  the  dissecting-room." — Journal  0/ American  Medical  Association. 

"Should  be  in  the  hands  of  every  medical  student." — Cleveland  Medical  Gazette. 

"  A  concise  and  judicious  work." — Buffalo  Medical  and  Surgical  Journal. 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College 
of  Philadelphia.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations,  and  includes  the  following  sections :  General 
Diseases,  Diseases  of  the  Digestive  Organs,  Diseases  of  the  Respiratory 
System,  Diseases  of  the  Circulatory  System,  Diseases  of  the  Nervous  Sys- 
tem, Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  and  Diseases  of  the 
Skin.  Each  section  is  prefaced  by  a  chapter  on  General  Symptomatology. 
Post  8vo,  520  pages.  Numerous  illustrations  and  selected  formulae. 
Price,  $2.^0,  bound  in  flexible  leather. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  P>om  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


1 8  IV.   B.   SAUNDERS 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

Bv  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Demonstrator  of  Patholog>'  in  the  Woman's 
Medical  College  of  Philadelphia.     445  pages.     Price,  Cloth,  $2.25. 

SECOND    EDITION,    REVISED. 

This  whollv  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copceia,  comprehends  the  following  sections:  Physiological  Action  of  Drugs; 
Drugs  ;  Remedial  Measures  other  than  Drugs  ;  Applied  Therapeutics  ;  Incom- 
patibility in  Prescriptions ;  Table  of  Doses  ;  Index  of  Drugs ;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulse. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare."—  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfuUj'  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  , 
and  it  will  be  found  a  reliable  guide."— l/nzversitj/  Medical  Magazine. 


NOTES  ON  THE  NEWER  REMEDIES:    their  Therapeutic  Ap- 
plications and  Modes  of  Administration.     By  David  Cerna,  M.  D., 

Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  $1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE   CHART.     Prepared  by  D.  T.  L.mne,  M.  D.      Size 

8x  i3j/<  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  1 9 

SAUNDERS*  POCKET  MEDICAL  LEXICON;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
Keating,  M.  D.,  editor  of  **  Cyclopcedia  of  Diseases  of  Children,"  etc. ; 
author  of  the  "  New  Pronouncing  Dictionary  of  Medicine;"  and  Henrv 
Hamilton,  author  of  "  A  New  Translation  of  Virgil's  -^Eneid  into  Eng- 
lish Verse  ;"  co-author  of  a  "  New  Pronouncing  Dictionary  of  Medicine.'" 
A  new  and  revised  edition.  32mo,  282  pages.  Prices:  Cloth,  75  cents* 
Leather  Tucks,  ^i.oo.     ' 

This  new  and  comprehensive  work  of  reference  is  the  outcome  of  a  demand 
for  a  more  modern  handbook  of  its  class  than  those  at  present  on  the  market, 
which,  dating  as  they  do  from  1855  ^^  1884,  are  of  but  trifling  use  to  the  student 
by  their  not  containing  the  hundreds  of  new  words  now  used  in  current  Utera- 
ture,  especially  those  relating  to  Electricity  and  Bacteriology. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  A.^^x{\\\on." —Journal  of  Anter^ 
ican  Medical  Association. 

"Brief,  yet  complete  ....  it  contains  the  very  latest  nomenclature  in  even  the  newest 
departments  of  medicine." — Neiv  York  Medical  Record. 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions ;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Fourth 
edition,  revised  and  greatly  enlarged.  Handsomely  bound  in  morocco, 
with  side  index,  wallet,  and  flap.     Price,  $1.75  net. 

A  concise,  clear,  and  correct  record  of  the  many  hundreds  of  famous  formulae 
which  are  found  scattered  through  the  works  of  the  most  eminent  physicians 
and  surgeons  of  the  world.  The  work  is  helpful  to  the  student  and  practitioner 
alike,  as  through  it  they  become  acquainted  with  numerous  formulae  which  are 
not  found  in  text-books,  but  have  been  collected  from  among  the  rising  genera- 
tion of  the  profession,  college  professors.,  and  hospital  physicians  and  surgeons. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given  is  unusually  reliable." — Ne-M  York  Medical  Record. 

"  Designed  to  be  of  immense  help  to  the  general  practitioner  in  the  exercise  of  his  daily 
calling  " — Boston  Medical  and  Surgical  journal. 


20  IV.   B.   SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.  M.,  M.  D., 
Professor  of  Gynecology  and  Obstetrics  in  the  New  York  School  of  Clinical 
Medicine ;  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dis- 
pensary, New  York  City.  In  one  handsome  octavo  volume  of  728  pages, 
illustrated  by  335  engravings  and  colored  plates.  Prices  :  Cloth,  ^4.00  net ; 
Sheep  or  Half  Morocco,  $5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  ih.^  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

Second  Edition,  Tlioroiighly  Revised, 

The  first  edition  of  this  work  rnet  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  hundred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  coimsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 

Professor  0/  Clinical  Gynecology ,  Medical  College  of  Ohio ;   Gynecologist  to  the  Good 

Samaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
?jid  practical. 


CATALOGUE    OF  MEDICAL    WORK'S.  21 


A  MANUAL    OF    PHYSIOLOGY,  with    Practical    Exercises.     For 

Students  and  Practitioners.  Hy  (i.  N.  Si  kwart,  M.  A.,  M.  D,  D.  Sc 
lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  New' 
Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 
Reserve  University,  Cleveland,  Ohio.  Handsome  octavo  vokime  of  800 
pages,  with  278  illustrations  in  the  text,  and  5  colored  plates.  Price, 
Cloth,  $3.50  net. 

,."  ^'  ^''i  '";*'^*^  'f.  y^y  by  sheer  force  of  merit,  and  a,npiy  deserves  to  do  so.     It  is  one  of 
the  very  best  English  text-books  o^  the  subject. '  '—London  Lancet.  ^ 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearlv 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume."-Z.'r///^/,  Medical  Journal         ^ 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Curwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

SYLLABUS    OF    OBSTETRICAL    LECTURES    in   the   Medical 

Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  Ihe  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child 
etc.  Ihe  paragraiphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant ;  no  minor  matters  omitted  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise.  '—New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  ;^2.00. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors 
to  '  An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

.ivl^?'nYw°/HH^^^''''^^"''y  'P-'"'^'^  "l?  ?^'"'  '"  '"^^'"g  bis  Syllabus  thoroughly  comprehen- 
refc;.nrl  !rAl=       "^"^  ""^ Vi^'  ^"'-^  ?""^^^  '°  '^'^  '""^t  '^^^^'  ^"thors  and  Operations      Full 


22  ^,   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net, 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used — viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surger)'  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antisepdcs 
needed  " — New  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." — Boston  Medical  and  Surgical  JourncU. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A,,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  countrj',  and 
we  predict  for  it  a  wide  circulation." — American  yournal  0/ Pharynacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henrj' 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.  Price, 
Cloth,  $1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  sp>ecial 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE   OF  MEDICAL    WORKS,  23 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Paediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  2 1 1  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  text.     Second  edition.     Price,  Cloth,  $2.00  net. 

"This  is  by  far  the  most  useful  bcxJk  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 

NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  484 
pages,  profusely  illustrated.     Price,  Cloth,  $2.00  net. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  ^2.CHD  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  con.sulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  tind  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART.  Designed  by  J.  P.  Crozer  Griffith, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania.   25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


24  PV.   B.   SAUNDERS' 


THE   CARE   OF   THE    BABY.      By  J.  P.  Crozer  Griffith,  M.  D., 

Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.      i2mo.      Price,  ^1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
•my  practitioners  who  have  not  had  large  opportunities  for  observing  children." — American 
Jjurnal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  m  the  ward  or  the  sick-room.  By  Honnor 
Morten,  author  of  "  How  to  Become  a  Nurse,"  "  Sketches  of  Hospital 
Life,"  etc.     i6mo,  140  pages.     Price,  Cloth,  ^i.oo. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physicia-n  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  ^1.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Ansemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric- Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  tiumbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "  An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  ^1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infani 
life ;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Fonnuh 
foi   tne  preparation  of  diluents  and  foods  are  appended. 


Saunders^ 
New  Series 
OF  Manuals 


for  Students 
and 
Practitioners. 


THAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  written  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner :  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  ^vorthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  Street,  Philadelphia, 


SAUNDERS'  NEW  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.     Price,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D,,  Demonstrator  of  Surgery,  Jefferson  Medical  College,  Philadelphia, 
etc.  Octavo,  911  pages,  386  illustrations.  Cloth,  $4.00  net;  Half- 
Morocco,  $5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,    M.  D.,  Demonstrator   of   Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc.     Price,  31.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  $1.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.  D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.      (Double  number.)     Price,  $2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases,  in  Rush  Medical  College,  Chicago.  (Double  number.) 
Price,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New 
York  Infirmary,  etc.     (Double  number.)      Price,  ^2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Asst.  Demonstrator 
of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital.     (Double  number.)     Price,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for  Women,  London;  and  Arthur  E.  Giles,  M.  D.,  B.  Sc.  Lond., 
F.  R.  C.  S.  Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women, 
London.  436  pages,  handsomely  illustrated.  (Double  number.)  Price, 
$2.50  net. 

VOLUMES   IN  PREPARATION. 
NERVOUS  DISEASES.     By  Charles  W.  Burr,  M.  D.,  Clinical  Pro- 
fessor of  Nervous  Diseases,  Medico-Chirurgical   College,  Philadelphia,  etc. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.  D.,  Clinical  Professor 
of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia. 

*if*  There  will   be   published   in  the    same  series,  at  short  intervals,  carefully 
prepared  works  on  various  subjects,  by  prominent  specialists. 


SAUNDERS'  QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form. 

THE  LATEST,  MOST  COMPLETE,  and  BEST  ILLUSTRATED 
SEEIES  OF- COMPENDS  EVEE  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


WITH 


Students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE    REASON    WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  do  help;  they  are 
the  leaders  in  their  special  line,  ivell  and  authoritatively  written  by  able  men, 
who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty-four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO   SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

*.:  *  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  over 
for  List). 


SAUNDERS'  QIESTION-COMPEND  SERIES, 

Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     3d  edition.     Illustrated.      Re- 

vised  and  enlarged  by  H.  A.  Hare,  M.  D      (Price,  $1.00  net.) 

2.  ESSENTIALS  OF  SURGERY.     6th  edition,  with   an  Appendix  on 

Antiseptic  Surger)-,     90  illustrations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF  ANATOMY.    5th  edition,  with  an  Appendix.     180 

il.usnar.ons.     By  Charles  B.  Nancrede,  M.  D. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 

INORGANIC.  4th  edition,  revised,  with  an  Appendix.  By  Law- 
rence Wolff,  M.  D. 

5.  ESSENTIALS    OF    OBSTETRICS.     4th  edition,    revised    and    en- 

larged.    75  illustrations.      By  \V.  Easterly  Ashton.  M.  D, 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY. 

7th  thousand.     46  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA   MEDICA,    THERAPEUTICS, 

AND  PRESCRIPTION-WRITING.  4th  edition.  By  Henry 
Morris.  M.  D. 

8.  9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.     By  Henry 

MuRRis,  M.  D.  An  Appendix  on  Urine  Examination.  Illustrated. 
By  Lawrence  Wolff,  M.  D.  3d  edition,  enlarged  by  some  300  Es- 
sential Formulae,  selected  from  eminent  authorities,  by  Wm.  M.  Powell, 
M.  D.     (Double  number,  price  S2. 00.) 

10.  ESSENTIALS  OF  GYNAECOLOGY.     4th  edition,  rev-ised.     With 

62  illustrations.     By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES   OF  THE  SKIN.     3d  edition,  re- 

vised and  enlarged.  71  letter-press  cuts  and  15  half-tone  illustrations. 
Bv  Henry  W.  Stelwagon,  M.  D.     (Price,  $1.00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND 

VENEREAL  DISEASES.  20  edition,  revised  and  enlarged.  78 
illustration-^.     By  Edward  Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND 

HYGIENE.      130  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

14.  ESSENTIALS  OF  DISEASES   OF  THE  EYE,  NOSE,  AND 

THROAT.  124  liiustrations.  2d  edition,  revised.  By  Edward 
Jackson.  M.  D..  and  E.  Baldwin  Gleason,  M.  D. 

15.  ESSENTIALS  OF  DISEASES  OF   CHILDREN.     Second  edi- 

tion.    Bv  William  H.  Powell.  M.  D. 
6.  ESSENTIALS    OF    EXAMINATION     OF    URINE.      Colored 
''  VoGEL  Scale,"  and  numerous  illustrations.     By  Lawrence  Wolff, 
M.  D.     I  Price,  75  cents. 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis-Cohen,  M.  D.,  and 

A.  A.  EsHNER.  ^L  D.     55  illustrations,  some  in  colors.    (Price, $1.50 net.) 

18.  ESSENTIALS   OF    PRACTICE    OF   PHARMACY.     By   L.   E. 

Sayre.     2d  edition,  revised. 

20.  ESSENTIALS    OF    BACTERIOLOGY.     3d  edition.     82   illustra- 

tirr.s.     Bv  M.  V.  Ball,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY 

4S  illustraiions.     3d  edition,  revised.     By  John  C.  Shaw,  >L  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.      155  illustrations.     2d 

edition,  revised.     By  Fred  J.  Brockwav.  M.  D.     (Price,  5i.oo  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations. 

Bv  David  D.  Stewart.  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.    By  E.  B.  Glea- 

son, M.  D.     114  illustrations.     Second  edition,  revised  and  enlarged. 


RECENT  PUBLICATIONS 


PENROSE'S  DISEASES  OF  WOMEN 

A  Text-Book   of   Diseases  of   Women.      Bv  Chari.ks  B.  Pknrosi;,  M.D     Ph  D 
Prolessor  of  (iyiiecology  in  the  University  of  f'eriMsylvaiiia  ;  SuiKeoii  to  tiie  (i'ytiecean 
Hospital,  Philadelphia.    Octavo  volume  of  529  pages,  hatidsomelv  illustrated.     Cloth 
I.V50  Jiet. 

"I  shall  value  very  highly  the  copy  of  Penrose's  "Diseases  of  Women  "  received. 
I  have  already  recommended  it  to  my  class  as  thk  bkst  book."— Howard  A  Kklly 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md.  ' 

SENN'S  GENITO=URINARY  TUBERCULOSIS 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By  Nicholas 
Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo  volume  of  ^20  pages 
illustrated.     Cloth,  53.00  net.  »-  e.     . 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant  Surgeon  to  Middle- 
sex Hospital,  and  Surgeon  to  Chelsea  Hospital,  London;  and  Arthur  E.  Gilks, 
M.D.,  B.Sc.  Lond.,  F  R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital,  London. 
436  pages,  handsomely  illustrated.     Cloth,  52.50  net. 

BUTLER'S   MATERIA  MEDICA,  THERAPEUTICS,  AND   PHAR= 
MACOLOQY.     Second  Edition,  Revised 

A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology.  By  George 
.  F.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia  Medica  and  of  Clinical  Medicine  in 
the  College  of  Physicians  and  Surgeons,  Chicago;  Professor  of  Materia  Medica  and 
Therapeutics,  Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  858 
pages,  illustrated.     Cloth,  $4.00  net ;  Sheep,  $5.00  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.D.  Edin., 
Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Roval  Medico-Chirur- 
gical  Society ;  Physician  to  the  General  Hospital;  Consulting  Phvsician  to  the  Eye 
Hospital  and  to  the  Hospital  for  Diseases  of  Women  ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illustrations 
and  4  colored  plates.    Cloth,  $2.50  net. 

PYE'S  BANDAGING 

Elementary  Bandaging  and  Surgical  Dressing,  with  Directions  Concerning 
the  Immediate  Treatment  of  Cases  of  Emergency.  For  the  Use  of  Dressers 
and  Nurses.  By  Walter  Pve,  F. R.C.S. ,  Late  Surgeon  to  St.  Marv's  Hospital, 
London.  Small  i2mo,  with  over  80  illustrations.  Cloth,  flexible  covers.  Price,  75 
cents  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE 

Pathological  Technique.  By  Frank  B.  Mallory,  A.M.,  M.D.,  Assistant  Professor 
of  Pathology,  Harvard  University  Medical  School;  and  James  H.  Wright,  A.M., 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School.  Octavo  volume 
of  396  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

"I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say 
that  I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  infor- 
mation, and  well  up  to  date."— William  H.  yN ki^ch.  Professor  of  Pathology,  Johns 
Hopkins  University,  Baltimore,  Md. 

ANDERS'  PRACTICE  OF  MEDICINE.     Second  Edition 

A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders.  M.D.,  Ph.D., 
LL.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Medico- 
Chirurgical  College,  Philadelphia.  In  one  handsome  octavo  volume  of  1287  pages, 
fully  illustrated.    Cloth,  $5.50  net ;  Sheep  or  Half  Morocco,  $6.50  net. 


ANOMALIES 

AND 

CURIOSITIES   OF    MEDICINE. 

BY 

GEORGE  M.  GOULD,  M.  D.,  and  WALTER  L.  PYLE.  ^^  D. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  material 
for  this  work,  fledical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  wnll  be  of  extreme  value  to  the  author  and  lecturer,  have 
been  arranged  and  annotated,  and  full  rei'erence  footnotes  given,  indicating 
whence  they  have  been  obtained. 

In  \iew  of  the  persistent  and  dominant  interest  in  the  anomalous  and  curious, 
a  thorough  and  systematic  collection  of  this  kind  (the  first  of  which  the 
authors  have  knowledge)  must  have  its  own  peculiar  sphere  of  usefulness. 

As  a  complete  and  authoritative  Book  of  Reference  it  will  be  of  value. 
not  only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in 
general  scientific,  sociologic,  and  medico-legal  topics ;  in  fact,  the  general  inter- 
est of  the  subject  and  the  dearth   of  any  complete  work  upon  it   make  this 
volume  one  of  the  most  important  literary  innovations  of  the  day. 

An  especially  valuable  feature  of  the  book  consists  of  the  Indexing. 
Besides  a  complete  and  comprehensive  General  Index,  containing  numerous 
cross-references  to  the  subjects  discussed,  and  the  names  of  the  authors  of  the 
more  important  repDrts.  there  is  a  convenient  Bibliographic  Index  and  a 
Table  of  Contents. 

The  plan  has  been  adopted  of  printing  the  topical  heading^S  in  bold^^ 
face  type,  the  reader  being  thereby  enabled  to  tell  at  a  glance  the  subject- 
matter  of  any  particular  paragraph  or  page. 

Illustrations  have  been  freely  employed  throughout  the  work,  there  being 
165  relief  cuts  and  130  half-tones  in  the  text,  and  12  colored  and  half-tone  full- 
page  plates — a  total  of  over  320  separate  figures. 

The  careful  rendering  of  the  text  and  references,  the  wealth  of  illustrations, 
the  mechanical  skill  represented  in  the  tN-pography,  the  printing,  and  the  bind- 
mg,  combine  to  make  this  book  one  of  the  most  attractive  medical  publications 
ever  issued. 


Handsome   Imperial  Octavo  Volume  of  968   Pages. 

PRICES:   Cloth,  $6.00  net;    Half    Morocco.   $7.00  net. 
30 


JUST  ISSUED 


AN   AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND   SKIN 
DISEASES 

EcUted  by  L.  Hoi.ton  Banc;s,  M.D.,  Late  Professor  of  Genito-Urinary  and  Venereal 
Diseases,  New  York  Post-Graduate  Medical  School  and  Hospital;  and  William 
A.  Hardavvay,  M.D.,  Professor  of  Distfases  of  the  Skin,  Missouri  Medical  CollcKe. 
Octavo  volume  of  over  1200  pages,  with  300  illustrations  in  the  text,  and  20  full-page 
colored  plates.     Prices:  Cloth,  $7.00  net  ;  Sheep  or  Half  Morocco,  $8.00  net. 

MOORE'S  ORTHOPEDIC  SURGERY 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D.,  Professor  of  Ortho- 
pedics and  Adjunct  Professor  of  Clinical  Surgery,  University  of  Minnesota,  College 
of  Medicine  and  Surgery,    gvo,  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT 

Surgical  Diagnosis  and  Treatment.  By  J.  \V.  Macdonai.d,  M.D.  Edin.,  L.R.C.S 
Edin.,  Professor  of  the  Practice  of  Surgery  and  of  Ciinica':  Surgery  in  Hamline  Uni- 
versity;  Visiting  Surgeon  to  St.  Barnabas'  Hospital,  Minneapolis,  etc.  Octavo 
volume  of  Soo  pages,  handsomely  illustrated.   Cloth,  $5.00  net ;  Half  Morocco,  |6.co  net. 

CHAPIN  ON  INSANITY 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.D.,  LL.D.,  Physician-in-Chiel, 
Pennsylvania  Hospital  for  the  Insane  ;  late  Physician-Superintendent  of  the  Willard 
State  Hospital,  New  York,  etc.     i2mo.,  "234  pages,  illustrated.     Cloth,  $1.25  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     By  Wm.  W  Keen, 

M.D.,  LL.D.,  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jeffer- 
son Medical  College,  Philada.     Octavo  volume  of  400  pages.     Cloth,  53.00  net' 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH 

Diseases  of  the  Stomach.  By  William  VV.  van  Valzah,  M.D.,  Professor  of  General 
Medicine  and  Diseases  of  the  Digestive  System  and  the  Blood,  New  York  Polyclinic  ; 
and  J.  Douglas  Nisbet,  M.D.,  Adjunct  Professor  of  General  ^Iedicine  and  Diseases 
of  the  Digestive  System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.     Cloth,  $3.50  net. 

IN  PREPARATION 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT 

Edited  by  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Jefferson 
Medical  College;  and  B.  Ale.xander  Randall,  M.D.,  Professor  of  Diseases  of  the 

Ear  in  the  University  of  Pennsylvania  and  in  the  Philadeli)hia  Polyclinic. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.D.,  Professor  of  Mental 
Diseases  and  Medical  Jurisprudence,  Northwestern  University  Medical  School, 
Chicago;  and  Frederick  Peterson,  M.D. ,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York,  etc. 

KYLE  ON  THE  NOSE  AND  THROAT 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor 
of  Laryngology  and  Rhinolog>',  Jefferson  Medical  College,  Philadelphia ;  Consulting 
Laryngologist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital,  etc. 

STENGEL'S  PATHOLOGY 

A  Manual  of  Pathology.  By  Alfred  Stengel,  M.D..  Physician  to  the  Philadel- 
phia Hospital;  Professor  of  Clinical  Medicine  in  the  Woman's  Medical  College; 
Physician  to  the  Children's  Hospital,  etc. 

HIRST'S  OBSTETRICS 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D.,  Professor  of  Ob 
stetrics.  University  of  Pennsylvania. 

HEISLER'S  EMBRYOLOGY 

A  Text-Book  of  Embryology.  By  John  C.  Heislkr,  M.D.,  Professor  of  Anatomy, 
Medico-Chirurgical  College,  Philadelphia. 


yoW  HEADY,    VOLUMES  FOB    1896,1897,1898, 


sa.tj:^ide:e^.s' 

AMERICAN  YEAR-BOOK  OF  MEDICINE  and  SURGERY. 

Edited    by  GEORGE  M.  GOULD,  A.  M.,  M.  D. 

Assisted  by  Eminent  American  Specialibts  and  Teachers. 


?i 


Notwithstanding  the  rajrid  multiplication  of  medical  and  sui^cal  works, 
still  these  publications  fail  to  meet  fiilly  the  requirements  of  the  general  physician^ 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text -books  of  well- 
known  [Hinciples  of  medical  science.  Mr.  Saunders  has  long  been  impressed 
with  this  fact,  which  is  confirmed  by  the  unanimity  of  expression  from  the  pro- 
fession at  large,  as  indicated  by  ad\ices  from  his  large  corps  of  canvassers. 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most 
practitioners  have  scant  access  to  this  almost  unlimited  source  of  information, 
and  the  busy  practiser  has  but  Uttle  time  to  search  out  in  periodicals  the  many 
interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his 
practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient 
form  CM  epitomisation  of  this  literature  by  persons  competent  to  pronounce  upon 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 
cannot  but  conmiand  his  highest  appreciation.     It  is  this  critical  and  judicial    $ 
function  that  will  be  assumed  by  the  Editorial  staff  of  the  "  American  Year- 
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It  is  the  special  purpose  of  the  Ekiitor,  whose  experience  pecuharly  qualifies  » 
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characteristicallv  international.  These  reviews  will  not  simply  be  a  series  of 
-:"  digested  abstracts  indiscriminately  run  together,  nor  will  they  be  retrospective  * 
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condensation  1^  experienced  writers  these  discussions  will  be 

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purpose,  thus  ensuring  accuracy  in  delineation,  affording  efficient  aids  to  a  right 
comprehension  of  the  text,  and  adding  to  the  attractiveness  of  the  volume. 
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Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.     By 

Dr.  Chk.  Jamji;,  ol  Erlangen.  Edited  by  Auuustus  A. 
EsHNER,  M.I).,  Professor  1  Clinical  Medicine  in  the  Phila- 
delphia Polyclinic ;  Attending  Physician  to  the  Philadelphia 
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delphia.     With  8o  colored  plates  from  original  water- colors. 
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Atlas  of  Orthopedic  Surgery. 
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Atlas  of  Psychiatry. 

Atlas  of  Diseases  of  the  Ear. 


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